Provider Demographics
NPI:1760546329
Name:NAIDU, VASANTHA (MD)
Entity Type:Individual
Prefix:
First Name:VASANTHA
Middle Name:
Last Name:NAIDU
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 1:654 E 47TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-4224
Mailing Address - Country:US
Mailing Address - Phone:773-624-4800
Mailing Address - Fax:773-624-5028
Practice Address - Street 1:654 E 47TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-4224
Practice Address - Country:US
Practice Address - Phone:773-624-4800
Practice Address - Fax:773-624-5028
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-056679207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D14102Medicare UPIN
367830Medicare PIN