Healthcare Provider Details

I. General information

NPI: 1740207331
Provider Name (Legal Business Name): VIJAY R HEGDE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 07/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 WYMAN ST UNIT #1
JAMAICA PLAIN MA
02130-1927
US

IV. Provider business mailing address

40 WYMAN ST UNIT #1
JAMAICA PLAIN MA
02130-1927
US

V. Phone/Fax

Practice location:
  • Phone: 410-477-9309
  • Fax:
Mailing address:
  • Phone: 410-477-9309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number227877
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number227877
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: