Healthcare Provider Details

I. General information

NPI: 1982792818
Provider Name (Legal Business Name): VIJAY VISWANATHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 11/30/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 S STATE ST
DOVER DE
19901-3530
US

IV. Provider business mailing address

640 S. STATE ST MAIL CODE 3055
DOVER DE
19901-3530
US

V. Phone/Fax

Practice location:
  • Phone: 302-480-1688
  • Fax: 302-480-9807
Mailing address:
  • Phone: 302-480-1688
  • Fax: 302-480-9807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberC1-0009394
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberC1-0009394
License Number StateDE
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberD0068887
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number230305
License Number StateMA
# 5
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberC1-0009394
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: