Provider Demographics
NPI:1265634513
Name:VASUDEVAN, VIJAYA NATTUVETTY (MD)
Entity Type:Individual
Prefix:
First Name:VIJAYA
Middle Name:NATTUVETTY
Last Name:VASUDEVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5600 MEXICO RD
Mailing Address - Street 2:STE 21
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-1660
Mailing Address - Country:US
Mailing Address - Phone:636-669-2219
Mailing Address - Fax:636-669-2380
Practice Address - Street 1:5600 MEXICO RD STE 21
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1660
Practice Address - Country:US
Practice Address - Phone:636-206-6022
Practice Address - Fax:780-328-3971
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO20020124317207RG0300X
MO2007007999207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine