Provider Demographics
NPI:1174603930
Name:JANVIRIYA, VICHA (MD)
Entity type:Individual
Prefix:MR
First Name:VICHA
Middle Name:
Last Name:JANVIRIYA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28750 SAN CARLOS
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076
Mailing Address - Country:US
Mailing Address - Phone:248-352-3297
Mailing Address - Fax:
Practice Address - Street 1:20905 GREENFIELD RD
Practice Address - Street 2:SUITE 603M
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-5360
Practice Address - Country:US
Practice Address - Phone:248-268-4464
Practice Address - Fax:248-268-4465
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032436208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2091256Medicaid
B44373Medicare UPIN
B44373Medicare UPIN