Basic Information
| Provider Information | |||||||||
| NPI: | 1033151915 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VASUDEVAN | ||||||||
| FirstName: | SUBRAMANIYAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 E SHERIDAN RD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329013122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217225200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1770 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329553133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218901500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 12/06/2019 | ||||||||
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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 | 2084P0800X | ME0035666 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 05487 | 01 | FL | BCBSFL | OTHER | 036059700 | 05 | FL | MEDICAID |