Provider Demographics
NPI:1144377193
Name:VAIDYA, SHAILENDRA SHANTIPRASAD (MD)
Entity Type:Individual
Prefix:MR
First Name:SHAILENDRA
Middle Name:SHANTIPRASAD
Last Name:VAIDYA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 PRESIDENTIAL BOULEVARD
Mailing Address - Street 2:UNIT 717
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-1152
Mailing Address - Country:US
Mailing Address - Phone:610-206-3801
Mailing Address - Fax:215-765-7776
Practice Address - Street 1:190 PRESIDENTIAL BOULEVARD
Practice Address - Street 2:UNIT 717
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1152
Practice Address - Country:US
Practice Address - Phone:610-206-3801
Practice Address - Fax:215-829-6427
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD034955L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA118028OtherAETNA
PA0007211070002Medicaid
PA02834OtherHEALTH PARTNERS
PA1034697OtherKEYSTONE MERCEY
PA0007211070002Medicaid