Provider Demographics
NPI:1659407211
Name:VADHAN, VIMLA P (PHD)
Entity Type:Individual
Prefix:DR
First Name:VIMLA
Middle Name:P
Last Name:VADHAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:CEDARHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11516-2315
Mailing Address - Country:US
Mailing Address - Phone:516-791-0111
Mailing Address - Fax:
Practice Address - Street 1:1 LONG BEACH ROAD
Practice Address - Street 2:BAYVIEW NURSING HOME
Practice Address - City:ISLAND PARK
Practice Address - State:NY
Practice Address - Zip Code:11558
Practice Address - Country:US
Practice Address - Phone:516-432-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013260103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01808406Medicaid
NY01808406Medicaid