Basic Information
| Provider Information | |||||||||
| NPI: | 1528179884 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VASUDEVAN | ||||||||
| FirstName: | VINODH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9059 W LAKE PLEASANT PKWY STE E-540 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6323223380 | ||||||||
| FaxNumber: | 6233224399 | ||||||||
| Practice Location | |||||||||
| Address1: | 9059 W LAKE PLEASANT PKWY STE E-540 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6323223380 | ||||||||
| FaxNumber: | 6233224399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 07/22/2019 | ||||||||
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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 | 208000000X | 35728 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 168411-01 | 05 | AZ | MEDICAID |