Healthcare Provider Details

I. General information

NPI: 1669480224
Provider Name (Legal Business Name): PUTHENPARAMPIL G VIJAYAKUMARAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: P G VIJAYAKUMARAN MD

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33101 ANNAPOLIS SUITE B
WAYNE MI
48184-2405
US

IV. Provider business mailing address

6508 KINGS COURT
WEST BLOOMFIELD MI
48322-2779
US

V. Phone/Fax

Practice location:
  • Phone: 734-721-0200
  • Fax: 734-721-2008
Mailing address:
  • Phone: 734-721-0200
  • Fax: 734-721-2008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301040605
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: