Healthcare Provider Details

I. General information

NPI: 1841269271
Provider Name (Legal Business Name): VIJAI SATHYAN TIVAKARAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 LITTLE YORK RD SUITE 20
DAYTON OH
45414-5800
US

IV. Provider business mailing address

4160 LITTLE YORK RD SUITE 20
DAYTON OH
45414-5800
US

V. Phone/Fax

Practice location:
  • Phone: 937-454-9527
  • Fax: 937-454-9532
Mailing address:
  • Phone: 937-454-9527
  • Fax: 937-454-9532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number219747
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number34008775
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: