Provider Demographics
NPI:1104033950
Name:VAIDYANATHAN, SURYA (MD)
Entity Type:Individual
Prefix:
First Name:SURYA
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 1:951 NW 13TH ST
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-2359
Mailing Address - Country:US
Mailing Address - Phone:561-447-9341
Mailing Address - Fax:561-447-9352
Practice Address - Street 1:800 MEADOWS RD
Practice Address - Street 2:SUITE 1C
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-2304
Practice Address - Country:US
Practice Address - Phone:561-447-9341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1104932085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01141616OtherRAILROAD-MEDICARE
FL14JT0OtherBLUE CROSS AND BLUE SHIELD
FL004503200Medicaid
FLFZ310WMedicare PIN