Provider Demographics
NPI:1063458271
Name:VAIDYANATHAN, GAYATRI (MD)
Entity Type:Individual
Prefix:
First Name:GAYATRI
Middle Name:
Last Name:VAIDYANATHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 N. MAYFAIR ROAD
Mailing Address - Street 2:TOSA CENTER
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:414-456-8998
Mailing Address - Fax:414-955-6299
Practice Address - Street 1:1155 N. MAYFAIR ROAD
Practice Address - Street 2:TOSA CENTER
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-456-8998
Practice Address - Fax:414-955-6299
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51769-0202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry