Basic Information
Provider Information | |||||||||
NPI: | 1316082555 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VAIDYA | ||||||||
FirstName: | SHRIKANT | ||||||||
MiddleName: | K | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 449 | ||||||||
Address2: |   | ||||||||
City: | MARIETTA | ||||||||
State: | OH | ||||||||
PostalCode: | 45750 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403744500 | ||||||||
FaxNumber: | 7403745887 | ||||||||
Practice Location | |||||||||
Address1: | 2520 VALLEY DR | ||||||||
Address2: | SUITE 016 | ||||||||
City: | POINT PLEASANT | ||||||||
State: | WV | ||||||||
PostalCode: | 255502031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3046756060 | ||||||||
FaxNumber: | 3046755001 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/21/2007 | ||||||||
LastUpdateDate: | 06/14/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 13842 | WV | N |   | Other Service Providers | Specialist |   | 208800000X | 35.053340 | OH | Y |   | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | 0131036000 | 05 | WV |   | MEDICAID | 001707383 | 01 | WV | MOUNTAIN STATE BCBS | OTHER | 0544987 | 05 | OH |   | MEDICAID | CH5937 | 01 | WV | RAILROAD MEDICARE | OTHER |