Provider Demographics
NPI:1477550747
Name:VIDWANS, ANIRUDDHA (MD)
Entity Type:Individual
Prefix:
First Name:ANIRUDDHA
Middle Name:
Last Name:VIDWANS
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 1:65 KANE ST
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-2110
Mailing Address - Country:US
Mailing Address - Phone:860-523-6421
Mailing Address - Fax:860-523-3701
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-0001
Practice Address - Country:US
Practice Address - Phone:860-679-3105
Practice Address - Fax:860-679-1403
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0366842080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1366849Medicaid
CT1366849Medicaid
CT370001308Medicare PIN