Provider Demographics
NPI:1154308807
Name:JAIN, VASUDHA (MD)
Entity Type:Individual
Prefix:DR
First Name:VASUDHA
Middle Name:
Last Name:JAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VASUDHA
Other - Middle Name:P
Other - Last Name:MUTTAGI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157
Mailing Address - Country:US
Mailing Address - Phone:336-716-6157
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157
Practice Address - Country:US
Practice Address - Phone:336-716-6157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200401103207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
I18108Medicare UPIN
NC2033066Medicare ID - Type Unspecified