Provider Demographics
NPI:1023571924
Name:MADISETTY, VIGNESH
Entity Type:Individual
Prefix:
First Name:VIGNESH
Middle Name:
Last Name:MADISETTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 ARCH ST STE 303
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44304-1432
Mailing Address - Country:US
Mailing Address - Phone:330-375-6262
Mailing Address - Fax:
Practice Address - Street 1:490 POST ST STE 830
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-1409
Practice Address - Country:US
Practice Address - Phone:415-900-3350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1050161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program