Healthcare Provider Details

I. General information

NPI: 1902065261
Provider Name (Legal Business Name): SANJAY VIJAYA THEKKEURUMBIL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2008
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7430 N. SHADELAND AVE SUITE 200
INDIANAPOLIS IN
46250
US

IV. Provider business mailing address

6626 E 75TH ST STE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-0668
  • Fax: 317-577-7538
Mailing address:
  • Phone: 317-621-1647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number01071898A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: