Provider Demographics
NPI:1598754459
Name:VRIDHACHALAM, SANJEEVI (MD)
Entity Type:Individual
Prefix:
First Name:SANJEEVI
Middle Name:
Last Name:VRIDHACHALAM
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 1:10945 N PORT WASHINGTON RD STE 201
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5078
Mailing Address - Country:US
Mailing Address - Phone:262-292-3151
Mailing Address - Fax:
Practice Address - Street 1:10945 N PORT WASHINGTON RD STE 201
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5078
Practice Address - Country:US
Practice Address - Phone:262-292-3151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ336122085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ932485Medicaid
102827Medicare ID - Type UnspecifiedDOMRI
102829Medicare ID - Type UnspecifiedARL
102828Medicare ID - Type UnspecifiedEVDI
I28700Medicare UPIN