=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245299502
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VIJAYA SHASTRI MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2006
-----------------------------------------------------
Last Update Date | 02/24/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3950 HOLLYWOOD RD SUITE 270
-----------------------------------------------------
City | SAINT JOSEPH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49085-9159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-983-3386
-----------------------------------------------------
Fax | 269-983-7943
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3950 HOLLYWOOD RD SUITE 270
-----------------------------------------------------
City | SAINT JOSEPH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49085-9159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-983-3386
-----------------------------------------------------
Fax | 269-983-7943
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RA0000X
-----------------------------------------------------
Taxonomy Name | Adolescent Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | VS040679
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------