Provider Demographics
NPI:1003042672
Name:VADADA, DEEPAK (MD)
Entity Type:Individual
Prefix:
First Name:DEEPAK
Middle Name:
Last Name:VADADA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:55 WATER STREET
Mailing Address - Street 2:2ND FLOOR CRED DEPT
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10041-0004
Mailing Address - Country:US
Mailing Address - Phone:646-680-2888
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:1050 CLOVE RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3627
Practice Address - Country:US
Practice Address - Phone:718-816-6440
Practice Address - Fax:718-816-3611
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYAL4088604171207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03351342Medicaid
NYA400160802Medicare PIN