Healthcare Provider Details

I. General information

NPI: 1629066386
Provider Name (Legal Business Name): PUVALAI VIJAYKUMAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 01/20/2020
Certification Date: 01/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 WATSON BLVD
WARNER ROBINS GA
31093-3606
US

IV. Provider business mailing address

1707 WATSON BLVD
WARNER ROBINS GA
31093-3606
US

V. Phone/Fax

Practice location:
  • Phone: 478-929-8030
  • Fax: 478-929-8095
Mailing address:
  • Phone: 478-929-8030
  • Fax: 478-929-8095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number18484
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35071686V
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD041441E
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number084192
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: