Provider Demographics
NPI:1093206070
Name:VYAS, RAJIV PRADEEP (MD)
Entity type:Individual
Prefix:
First Name:RAJIV
Middle Name:PRADEEP
Last Name:VYAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 COLCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-1473
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:75 BEEKMAN ST
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-1438
Practice Address - Country:US
Practice Address - Phone:518-561-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-24
Last Update Date:2025-09-23
Deactivation Date:2019-01-22
Deactivation Code:
Reactivation Date:2019-01-31
Provider Licenses
StateLicense IDTaxonomies
NY3384832085R0202X
MA390200000X
MI4301115793390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology