Provider Demographics
NPI:1598733685
Name:VIJAYVARGIYA, MAMTA VED (MD)
Entity type:Individual
Prefix:
First Name:MAMTA
Middle Name:VED
Last Name:VIJAYVARGIYA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MAMTA
Other - Middle Name:VED
Other - Last Name:GUPTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:770 W GRANADA BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5179
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1061 MEDICAL CENTER DR STE 110
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8225
Practice Address - Country:US
Practice Address - Phone:386-917-7594
Practice Address - Fax:386-456-3257
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2025-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83720207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264036800Medicaid
H25104Medicare UPIN
FL264036800Medicaid