Healthcare Provider Details

I. General information

NPI: 1174018642
Provider Name (Legal Business Name): VISHNUVENI LEELARUBAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VISHNUVENI KANDASAMY

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 S QUEEN ST
DOVER DE
19904-3568
US

IV. Provider business mailing address

355 BARD AVE DEPT OF
STATEN ISLAND NY
10310-1664
US

V. Phone/Fax

Practice location:
  • Phone: 302-678-4488
  • Fax: 302-678-4497
Mailing address:
  • Phone: 718-818-2419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA12769100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC1-0024260
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: