Individual
SANDEEP SURESH VIJAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
23450 US HIGHWAY 160, WALSENBURG, CO 81089-8100
(719) 738-4588
(719) 738-4534
Mailing address
23500 US HIGHWAY 160, WALSENBURG, CO 81089-9524
(719) 738-5100
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
48414
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
15579026
—
CO
01
—
COA102479
MEDICARE PTAN
CO
Enumeration date
02/09/2007
Last updated
11/28/2023
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