Provider Demographics
NPI:1225220940
Name:RAGHU, VIJAYALAKSHMI (MD)
Entity type:Individual
Prefix:
First Name:VIJAYALAKSHMI
Middle Name:
Last Name:RAGHU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3365 REGENT BLVD
Mailing Address - Street 2:STE 110
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-3125
Mailing Address - Country:US
Mailing Address - Phone:972-905-3917
Mailing Address - Fax:940-205-4525
Practice Address - Street 1:3365 REGENT BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-3122
Practice Address - Country:US
Practice Address - Phone:972-905-3917
Practice Address - Fax:940-205-4525
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-01163207Q00000X
TXN8561207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXN8561OtherMEDICAL LICENSE
TX340614YKY6OtherMEDICARE NUMBER
TX340614ZQ43Medicare PIN
TXTXB142987Medicare PIN