Provider Demographics
NPI:1871512806
Name:VIJAYVARGIYA, MANJU (MD)
Entity type:Individual
Prefix:
First Name:MANJU
Middle Name:
Last Name:VIJAYVARGIYA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8792
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-8792
Mailing Address - Country:US
Mailing Address - Phone:440-285-6000
Mailing Address - Fax:216-844-5922
Practice Address - Street 1:13207 RAVENNA RD
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-7032
Practice Address - Country:US
Practice Address - Phone:440-285-6000
Practice Address - Fax:216-844-5922
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-8951-V2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0549179Medicaid