Provider Demographics
NPI:1528014651
Name:VASUDEVAN, SRIDHAR V (MD)
Entity Type:Individual
Prefix:
First Name:SRIDHAR
Middle Name:V
Last Name:VASUDEVAN
Suffix:
Gender:M
Credentials:MD
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W129N7055 NORTHFIELD DR
Mailing Address - Street 2:PHYSICAL MEDICINE AND REHABILITATION
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-0538
Mailing Address - Country:US
Mailing Address - Phone:262-253-5400
Mailing Address - Fax:262-253-7162
Practice Address - Street 1:W129N7055 NORTHFIELD DR
Practice Address - Street 2:PHYSICAL MEDICINE AND REHABILITATION
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-0538
Practice Address - Country:US
Practice Address - Phone:262-253-5400
Practice Address - Fax:262-253-7162
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI20559208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1528014651Medicaid
000068108Medicare ID - Type Unspecified
000602096Medicare ID - Type Unspecified
WI680860471Medicare PIN
E72260Medicare UPIN
000140225Medicare ID - Type Unspecified