Provider Demographics
NPI:1922059153
Name:VEDULA, VANDANA (MD)
Entity Type:Individual
Prefix:
First Name:VANDANA
Middle Name:
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 1:1201 SOUTH DR STE 352
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-3255
Mailing Address - Country:US
Mailing Address - Phone:989-779-5277
Mailing Address - Fax:989-779-5278
Practice Address - Street 1:1201 SOUTH DR STE 352
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-3255
Practice Address - Country:US
Practice Address - Phone:989-779-5277
Practice Address - Fax:989-779-5278
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079152207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4622662Medicaid
H76348Medicare UPIN