Healthcare Provider Details

I. General information

NPI: 1245299502
Provider Name (Legal Business Name): VIJAYA SHASTRI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 02/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 HOLLYWOOD RD SUITE 270
SAINT JOSEPH MI
49085-9159
US

IV. Provider business mailing address

3950 HOLLYWOOD RD SUITE 270
SAINT JOSEPH MI
49085-9159
US

V. Phone/Fax

Practice location:
  • Phone: 269-983-3386
  • Fax: 269-983-7943
Mailing address:
  • Phone: 269-983-3386
  • Fax: 269-983-7943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License NumberVS040679
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: