Provider Demographics
NPI:1205000452
Name:NAIDU, VASANTHAN G (MD)
Entity Type:Individual
Prefix:DR
First Name:VASANTHAN
Middle Name:G
Last Name:NAIDU
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 1:504 S DRAPER AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-3842
Mailing Address - Country:US
Mailing Address - Phone:217-778-5454
Mailing Address - Fax:
Practice Address - Street 1:504 S DRAPER AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-3842
Practice Address - Country:US
Practice Address - Phone:217-778-5454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-18
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.124108207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine