Healthcare Provider Details

I. General information

NPI: 1467441790
Provider Name (Legal Business Name): VIJAYA L NAGABHAIRU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 03/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 S FLORIDA ST
BUSHNELL FL
33513-6703
US

IV. Provider business mailing address

39 E ATWATER AVE SUITE A
EUSTIS FL
32726-5540
US

V. Phone/Fax

Practice location:
  • Phone: 352-793-2441
  • Fax: 352-793-3282
Mailing address:
  • Phone: 352-483-0900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME89894
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: