Provider Demographics
NPI:1871565200
Name:THANDRA, VIJAYA RAO (MD)
Entity type:Individual
Prefix:
First Name:VIJAYA
Middle Name:RAO
Last Name:THANDRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VIJAYALAKSMI
Other - Middle Name:RAO
Other - Last Name:THANDRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2607 RIVER RUN RD
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-7264
Mailing Address - Country:US
Mailing Address - Phone:248-981-7139
Mailing Address - Fax:
Practice Address - Street 1:2607 RIVER RUN RD
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-7264
Practice Address - Country:US
Practice Address - Phone:248-981-7139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ5936207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0808262241OtherBLUCROSS BLUSHIELD
MI4326290-10Medicaid
MIN32810002Medicare PIN
MI4326290-10Medicaid
MIP47600002Medicare PIN