Basic Information
Provider Information | |||||||||
NPI: | 1215041975 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VASUDEVAN | ||||||||
FirstName: | SREEKALA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 COPELAND DR | ||||||||
Address2: |   | ||||||||
City: | MANSFIELD | ||||||||
State: | MA | ||||||||
PostalCode: | 020481225 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5083394144 | ||||||||
FaxNumber: | 5082619940 | ||||||||
Practice Location | |||||||||
Address1: | 200 COPELAND DR | ||||||||
Address2: |   | ||||||||
City: | MANSFIELD | ||||||||
State: | MA | ||||||||
PostalCode: | 020481225 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5083394144 | ||||||||
FaxNumber: | 5082619940 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/19/2006 | ||||||||
LastUpdateDate: | 08/26/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD 9085 | RI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RR0500X | 257722 | MA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
ID | Type | State | Issuer | Description | 0000023389 | 01 |   | RIBC | OTHER | 789085 | 01 |   | TUFTS | OTHER | 847334 | 01 |   | COVENTRY | OTHER | 061480182 | 01 |   | AETNA | OTHER | AA7552 | 01 |   | HPHC | OTHER | 0000176100909 | 01 |   | UHC | OTHER | 5881310 | 01 |   | CIGNA | OTHER | 402618 | 01 |   | BLUE CHIP RI | OTHER |