Provider Demographics
NPI:1770575524
Name:VIJAYARAJ, SUGANTHI (MD)
Entity type:Individual
Prefix:
First Name:SUGANTHI
Middle Name:
Last Name:VIJAYARAJ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUGANTHI
Other - Middle Name:
Other - Last Name:ESWARAMOORTHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:840 RICHARD RD STE 3
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1994
Practice Address - Country:US
Practice Address - Phone:219-322-1450
Practice Address - Fax:219-322-8260
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059056A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200482150Medicaid
IL0090000854OtherBCBS GROUP NUMBER
IN200482150Medicaid
IN140220JJJMedicare PIN
IN140230MMMMedicare ID - Type Unspecified