=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730406836
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REKHA VIJAYAN MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2010
-----------------------------------------------------
Last Update Date | 07/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7300 N FRESNO ST
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93720-2941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-448-4060
-----------------------------------------------------
Fax | 877-735-3446
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7300 N FRESNO ST
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93720-2941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-448-4060
-----------------------------------------------------
Fax | 877-735-3446
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | 66073-20
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------