Basic Information
Provider Information
NPI: 1003015421
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DHEVAN
FirstName: VIJIAN
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208600000XP3310TXY Allopathic & Osteopathic PhysiciansSurgery 
208600000X125-052980ILN Allopathic & Osteopathic PhysiciansSurgery 

ID Information
IDTypeStateIssuerDescription
30284900605TX MEDICAID
H08JE0000101TXBCBSOTHER


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