Provider Demographics
NPI:1679772891
Name:KOMMAREDDI, VIJAYA K (MD)
Entity type:Individual
Prefix:DR
First Name:VIJAYA
Middle Name:K
Last Name:KOMMAREDDI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:VIJAYA
Other - Middle Name:K
Other - Last Name:KOMMAREDDI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3701 LOOP ROAD SUITE 210
Mailing Address - Street 2:VA MEDICAL CENTER
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35405-4998
Mailing Address - Country:US
Mailing Address - Phone:205-554-2000
Mailing Address - Fax:
Practice Address - Street 1:3701 LOOP ROAD SUITE 210
Practice Address - Street 2:VA MEDICAL CENTER
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35405
Practice Address - Country:US
Practice Address - Phone:205-554-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301089295207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3000890Medicare PIN