Healthcare Provider Details

I. General information

NPI: 1063474260
Provider Name (Legal Business Name): VIJAY KUMAR NELLORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 10/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUILDING 361,VAMCHS MANAGED CARE
PERRY POINT MD
21902
US

IV. Provider business mailing address

7 DIXIE DR
BEL AIR MD
21014-5410
US

V. Phone/Fax

Practice location:
  • Phone: 410-642-2411
  • Fax:
Mailing address:
  • Phone: 410-836-8584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberD21779
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: