Provider Demographics
NPI:1689685927
Name:CHELLAM VEDAMUTHU, NISHA (MD)
Entity Type:Individual
Prefix:DR
First Name:NISHA
Middle Name:
Last Name:CHELLAM VEDAMUTHU
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 1:8550 SANTA MONICA BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-4496
Mailing Address - Country:US
Mailing Address - Phone:909-962-1260
Mailing Address - Fax:
Practice Address - Street 1:8550 SANTA MONICA BLVD FL 2
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-4496
Practice Address - Country:US
Practice Address - Phone:909-962-1260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061862207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MHG44049Medicare UPIN