Healthcare Provider Details

I. General information

NPI: 1659378008
Provider Name (Legal Business Name): VIJAYAKUMAR PRAVEEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 05/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4351 E LOHMAN AVE SUITE 100
LAS CRUCES NM
88011-8259
US

IV. Provider business mailing address

4351 E LOHMAN AVE SUITE 100
LAS CRUCES NM
88011-8259
US

V. Phone/Fax

Practice location:
  • Phone: 575-532-9077
  • Fax: 575-532-9221
Mailing address:
  • Phone: 575-532-9077
  • Fax: 575-532-9221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number043312
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberMD2009-0599
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: