Provider Demographics
NPI:1902024623
Name:TANGELLA, VIJAYA K (MD)
Entity Type:Individual
Prefix:DR
First Name:VIJAYA
Middle Name:K
Last Name:TANGELLA
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 1:750 W OLIVE AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-2436
Mailing Address - Country:US
Mailing Address - Phone:209-384-3115
Mailing Address - Fax:209-384-0878
Practice Address - Street 1:750 W OLIVE AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-2436
Practice Address - Country:US
Practice Address - Phone:209-384-3115
Practice Address - Fax:209-384-0878
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45065174400000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A450650Medicare ID - Type Unspecified
CAE92731Medicare UPIN