Provider Demographics
NPI:1104267384
Name:GORANTLA, VIJAY S (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:VIJAY
Middle Name:S
Last Name:GORANTLA
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 TERRACE ST
Mailing Address - Street 2:SUITE 670 SCAIFE HALL
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213-2500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3550 TERRACE ST
Practice Address - Street 2:SUITE 670 SCAIFE HALL
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-2500
Practice Address - Country:US
Practice Address - Phone:412-648-9677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD442279208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery