Provider Demographics
NPI:1124239553
Name:L VIJAYA. MD, PA
Entity type:Organization
Organization Name:L VIJAYA. MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:BRENDLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-492-8711
Mailing Address - Street 1:568 RUIN CREEK RD
Mailing Address - Street 2:SUITE 121
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-2880
Mailing Address - Country:US
Mailing Address - Phone:252-492-8711
Mailing Address - Fax:252-492-2028
Practice Address - Street 1:568 RUIN CREEK RD
Practice Address - Street 2:STE. 121
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-2880
Practice Address - Country:US
Practice Address - Phone:252-492-8711
Practice Address - Fax:252-492-2028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19957208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8985084Medicaid
NC8985084Medicaid
C80765Medicare UPIN
NC1039700002Medicare NSC