Provider Demographics
NPI:1871016352
Name:VADIVELAN, AKHILA ARCOT (MD)
Entity Type:Individual
Prefix:
First Name:AKHILA
Middle Name:ARCOT
Last Name:VADIVELAN
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 1:201 NW MEDICAL LOOP STE 190
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-8835
Mailing Address - Country:US
Mailing Address - Phone:541-677-4319
Mailing Address - Fax:541-677-2294
Practice Address - Street 1:2700 NW STEWART PKWY
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1281
Practice Address - Country:US
Practice Address - Phone:541-677-4319
Practice Address - Fax:541-677-2294
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-17
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD198808208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD198808OtherMEDICAL LICENSE