Healthcare Provider Details

I. General information

NPI: 1568522233
Provider Name (Legal Business Name): VIJAYALAXMI BOGAVELLI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VIJAYALAXMI JUVVADI M.D.

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 02/15/2021
Certification Date: 02/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9155 SW BARNES RD STE 333
PORTLAND OR
97225-6625
US

IV. Provider business mailing address

PO BOX 3158
PORTLAND OR
97208-3158
US

V. Phone/Fax

Practice location:
  • Phone: 503-216-5102
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD166266
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number95-01178
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD166266
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier500686948
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier5901479
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: