Healthcare Provider Details

I. General information

NPI: 1376745935
Provider Name (Legal Business Name): MADHU B VIJAYAPPA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MADHU BUKKASAGARA VIJAYAPPA M.D.

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8984 SW 64TH LN
GAINESVILLE FL
32608-8562
US

IV. Provider business mailing address

1702 UNIVERSITY DR S SSC - MEDICAL STAFF SERVICES
FARGO ND
58103-4940
US

V. Phone/Fax

Practice location:
  • Phone: 617-304-5318
  • Fax:
Mailing address:
  • Phone: 701-364-8177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number13954
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number45967
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: