Healthcare Provider Details

I. General information

NPI: 1386900397
Provider Name (Legal Business Name): VIVAK MAHENDRA MASTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 07/30/2020
Certification Date: 07/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 PUDDLEDOCK RD STE 400
PRINCE GEORGE VA
23875-1268
US

IV. Provider business mailing address

8001 FRANKLIN FARMS DR RM 130
RICHMOND VA
23229-5100
US

V. Phone/Fax

Practice location:
  • Phone: 804-458-1740
  • Fax: 804-541-1846
Mailing address:
  • Phone: 804-521-5800
  • Fax: 804-545-4340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number0101259987
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number0101259987
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: