Provider Demographics
NPI:1992599906
Name:JAGANATHAN, VIJAYADITHYAN
Entity type:Individual
Prefix:
First Name:VIJAYADITHYAN
Middle Name:
Last Name:JAGANATHAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 FLAMINGO CIR
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-2186
Mailing Address - Country:US
Mailing Address - Phone:205-410-0611
Mailing Address - Fax:
Practice Address - Street 1:745 W MOANA LN STE 300
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-4980
Practice Address - Country:US
Practice Address - Phone:775-327-5174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program