Healthcare Provider Details

I. General information

NPI: 1215972179
Provider Name (Legal Business Name): RADHIKA VIJAYAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 02/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE
HACKENSACK NJ
07601-1914
US

IV. Provider business mailing address

227 EMILY DR
PARK RIDGE NJ
07656-1055
US

V. Phone/Fax

Practice location:
  • Phone: 201-996-5430
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberMA038106
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number149645
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: