Provider Demographics
NPI:1427067511
Name:KANDULA, VIJAYABHASKAR REDDY (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:VIJAYABHASKAR
Middle Name:REDDY
Last Name:KANDULA
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:DR
Other - First Name:NONE
Other - Middle Name:
Other - Last Name:NONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, MPH
Mailing Address - Street 1:PO BOX 3299
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89702-3299
Mailing Address - Country:US
Mailing Address - Phone:844-207-4039
Mailing Address - Fax:775-222-0056
Practice Address - Street 1:1200 E 3900 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1300
Practice Address - Country:US
Practice Address - Phone:801-783-5011
Practice Address - Fax:801-746-3734
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79767207R00000X
UT7162989-1205207R00000X
NV18275208M00000X
UT7169289-1205208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH76227Medicare UPIN