Provider Demographics
NPI:1992892707
Name:PRATHA, VIJAYALAKSHMI S (MD)
Entity type:Individual
Prefix:
First Name:VIJAYALAKSHMI
Middle Name:S
Last Name:PRATHA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VIJAYA
Other - Middle Name:S
Other - Last Name:PRATHA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3330 3RD AVE STE 304
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-5639
Mailing Address - Country:US
Mailing Address - Phone:619-260-1012
Mailing Address - Fax:619-260-1727
Practice Address - Street 1:3330 3RD AVE STE 304
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5639
Practice Address - Country:US
Practice Address - Phone:619-260-1012
Practice Address - Fax:619-260-1727
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51136207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A511361Medicaid
CA00A511361Medicaid
CAA51136Medicare ID - Type Unspecified