Provider Demographics
NPI:1154851350
Name:VEDANTAM, NEETHU (MD)
Entity Type:Individual
Prefix:DR
First Name:NEETHU
Middle Name:
Last Name:VEDANTAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NEETHU
Other - Middle Name:PRABHAKARAN
Other - Last Name:NAIR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 SHERIDAN SQ STE 200
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-7435
Practice Address - Country:US
Practice Address - Phone:423-246-7931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN65494207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ042551Medicaid