Basic Information
| Provider Information | |||||||||
| NPI: | 1548264377 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAO | ||||||||
| FirstName: | VIVIAN | ||||||||
| MiddleName: | H. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 213 S JEFFERSON ST STE 1006 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240111713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402245715 | ||||||||
| FaxNumber: | 5402245684 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 HIGHLAND AVE SE | ||||||||
| Address2: | STE 104 | ||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240132255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403434423 | ||||||||
| FaxNumber: | 5403430495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 08/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 0101226188 | VA | N | Other Service Providers | Specialist | 207Y00000X | 0101226188 | VA | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 010415691 | 05 | VA | MEDICAID | VA0103 | 01 | VA | JOHN DEERE | OTHER | 040015083 | 01 | MEDICARE RR | OTHER | 299658 | 01 | VA | MAMSI | OTHER | 452106 | 01 | VA | ANTHEM | OTHER | 6502783 | 05 | VA | MEDICAID | 010415683 | 05 | VA | MEDICAID |