Provider Demographics
NPI:1629052964
Name:VAIDYA, KUMUDINI M (MD)
Entity Type:Individual
Prefix:
First Name:KUMUDINI
Middle Name:M
Last Name:VAIDYA
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 1069
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73023-1069
Mailing Address - Country:US
Mailing Address - Phone:405-224-8111
Mailing Address - Fax:405-574-7765
Practice Address - Street 1:2222 W IOWA AVE
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-2738
Practice Address - Country:US
Practice Address - Phone:405-224-8111
Practice Address - Fax:405-574-7765
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12249208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100005110AMedicaid
D35369Medicare UPIN
OK100005110AMedicaid