Provider Demographics
NPI:1760451769
Name:MAHADEVA, VIDUR SIDDHANTH (MD)
Entity Type:Individual
Prefix:
First Name:VIDUR
Middle Name:SIDDHANTH
Last Name:MAHADEVA
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 1:1441 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2837
Mailing Address - Country:US
Mailing Address - Phone:602-495-4577
Mailing Address - Fax:602-417-3549
Practice Address - Street 1:801 E WILLIAMS AVE
Practice Address - Street 2:
Practice Address - City:FALLON
Practice Address - State:NV
Practice Address - Zip Code:89406-3052
Practice Address - Country:US
Practice Address - Phone:775-423-3151
Practice Address - Fax:775-423-2853
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11257207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100508290Medicaid
NV100508290Medicaid
V101711Medicare PIN