Provider Demographics
NPI:1528179884
Name:VASUDEVAN, VINODH (MD)
Entity Type:Individual
Prefix:DR
First Name:VINODH
Middle Name:
Last Name:VASUDEVAN
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 1:9059 W LAKE PLEASANT PKWY STE E-540
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382
Mailing Address - Country:US
Mailing Address - Phone:632-322-3380
Mailing Address - Fax:623-322-4399
Practice Address - Street 1:9059 W LAKE PLEASANT PKWY STE E-540
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382
Practice Address - Country:US
Practice Address - Phone:632-322-3380
Practice Address - Fax:623-322-4399
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35728208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ168411-01Medicaid
AZI68861Medicare UPIN
AZ168411-01Medicaid