Healthcare Provider Details

I. General information

NPI: 1902830243
Provider Name (Legal Business Name): VIJAY SUBRAYA MAIYA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 02/25/2022
Certification Date: 02/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5505 S 900 E STE 240
MURRAY UT
84117-7210
US

IV. Provider business mailing address

PO BOX 3299
CARSON CITY NV
89702-3299
US

V. Phone/Fax

Practice location:
  • Phone: 801-783-5011
  • Fax: 801-746-3734
Mailing address:
  • Phone: 844-207-4039
  • Fax: 775-222-0056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number11909
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number8661504-1205
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number8661504-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: