Provider Demographics
NPI:1700048501
Name:VEDULA, GEETHA GANTI (MD)
Entity Type:Individual
Prefix:
First Name:GEETHA
Middle Name:GANTI
Last Name:VEDULA
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 1:1776 N PINE ISLAND RD STE 214
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33322-5223
Mailing Address - Country:US
Mailing Address - Phone:954-452-9922
Mailing Address - Fax:954-452-7574
Practice Address - Street 1:1776 N PINE ISLAND RD STE 214
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33322
Practice Address - Country:US
Practice Address - Phone:310-206-1166
Practice Address - Fax:310-301-8713
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA108911207W00000X
FLME107675207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003568900Medicaid
CA00A1089110Medicaid