Basic Information
| Provider Information | |||||||||
| NPI: | 1003015421 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DHEVAN | ||||||||
| FirstName: | VIJIAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 614 MACO DR | ||||||||
| Address2: | |||||||||
| City: | HARLINGEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785508450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9564409110 | ||||||||
| FaxNumber: | 9564409801 | ||||||||
| Practice Location | |||||||||
| Address1: | 614 MACO DR | ||||||||
| Address2: | |||||||||
| City: | HARLINGEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785508450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9564409110 | ||||||||
| FaxNumber: | 9564409801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2007 | ||||||||
| LastUpdateDate: | 04/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 125-052980 | IL | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | P3310 | TX | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | H08JE00001 | 01 | TX | BCBS | OTHER | 302849006 | 05 | TX | MEDICAID |