Provider Demographics
NPI:1144310475
Name:VIJAYABHANU, KALLURU (MD)
Entity type:Individual
Prefix:DR
First Name:KALLURU
Middle Name:
Last Name:VIJAYABHANU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MANIKONDA
Other - Middle Name:
Other - Last Name:VIJAYARHANU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8520 N GREENVALE RD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:WI
Mailing Address - Zip Code:53217
Mailing Address - Country:US
Mailing Address - Phone:414-228-9446
Mailing Address - Fax:
Practice Address - Street 1:5228 W FOND DU LAC AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216
Practice Address - Country:US
Practice Address - Phone:414-536-2100
Practice Address - Fax:414-536-2311
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37250207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G66698Medicare UPIN