Provider Demographics
NPI:1588693857
Name:ADIMOOLAM, VIJAY VENKATA (MD)
Entity type:Individual
Prefix:
First Name:VIJAY
Middle Name:VENKATA
Last Name:ADIMOOLAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:VENKATAVIJAYBABU
Other - Middle Name:
Other - Last Name:ADIMOOLAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6701 N. CHARLES STREET
Mailing Address - Street 2:S. CHAPMAN BUILDING, SUITE 102
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21204
Mailing Address - Country:US
Mailing Address - Phone:443-849-6775
Mailing Address - Fax:438-493-1384
Practice Address - Street 1:6565 N CHARLES ST STE 512
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-6826
Practice Address - Country:US
Practice Address - Phone:443-849-3400
Practice Address - Fax:443-849-3402
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN7385207RG0100X
OH35C.001833207RG0100X
IAMD-51129207RG0100X
VA0101278304207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX218995301Medicaid
TX218995301Medicaid