Provider Demographics
NPI:1447226212
Name:VAIDYANATHAN, RAMA (MD)
Entity Type:Individual
Prefix:
First Name:RAMA
Middle Name:
Last Name:VAIDYANATHAN
Suffix:
Gender:F
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:PO BOX 639295 DEPT 93394
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-9295
Mailing Address - Country:US
Mailing Address - Phone:248-842-6600
Mailing Address - Fax:855-618-6655
Practice Address - Street 1:2514 S 102ND ST
Practice Address - Street 2:STE. 160
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2142
Practice Address - Country:US
Practice Address - Phone:414-255-0300
Practice Address - Fax:414-543-9601
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47214207R00000X
TXT9267207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34566100Medicaid
WI34566100Medicaid