Provider Demographics
NPI:1821288499
Name:VEDATI, DURGA PRASAD (MD)
Entity Type:Individual
Prefix:
First Name:DURGA
Middle Name:PRASAD
Last Name:VEDATI
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:PO BOX 92994
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-0994
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 N MACARTHUR BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-7423
Practice Address - Country:US
Practice Address - Phone:248-787-6266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY51504207P00000X
AZ40394207QG0300X
IN01081121A208M00000X
ORMD217161208M00000X
TXN2331207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX205912302Medicaid
TX8CK692OtherBCBS
TX8L25853Medicare PIN