Basic Information
| Provider Information | |||||||||
| NPI: | 1568466365 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAIDYA | ||||||||
| FirstName: | KEDARNATH | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4248 | ||||||||
| Address2: | DEPT 102 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772104248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814443278 | ||||||||
| FaxNumber: | 8322493861 | ||||||||
| Practice Location | |||||||||
| Address1: | 17350 ST LUKES WAY | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | THE WOODLANDS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773844167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814443278 | ||||||||
| FaxNumber: | 8322493861 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 07/14/2016 | ||||||||
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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 | 207RC0000X | M3100 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | M3100 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207U00000X | M3100 | TX | N | Allopathic & Osteopathic Physicians | Nuclear Medicine |
ID Information
| ID | Type | State | Issuer | Description | 197962701 | 05 | TX | MEDICAID | 00J21A | 01 | TX | GROUP MEDICARE | OTHER |