Provider Demographics
NPI:1124091558
Name:CHUNDI, VIJAYA VARDHAN (MD)
Entity type:Individual
Prefix:DR
First Name:VIJAYA
Middle Name:VARDHAN
Last Name:CHUNDI
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 1:1825 SE TIFFANY AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7554
Mailing Address - Country:US
Mailing Address - Phone:772-398-2233
Mailing Address - Fax:772-398-2244
Practice Address - Street 1:1825 SE TIFFANY AVE STE 104
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952
Practice Address - Country:US
Practice Address - Phone:772-398-2233
Practice Address - Fax:772-398-2244
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME733202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4029Medicare ID - Type UnspecifiedGROUP
FL42271AMedicare ID - Type UnspecifiedINDIVIDUAL
FLF83224Medicare UPIN