Provider Demographics
NPI:1962486761
Name:VAIDY, PRAKASH
Entity Type:Individual
Prefix:DR
First Name:PRAKASH
Middle Name:
Last Name:VAIDY
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:PRAKASH
Other - Middle Name:
Other - Last Name:VAIDYANATHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1040
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21922-1040
Mailing Address - Country:US
Mailing Address - Phone:410-398-0590
Mailing Address - Fax:443-681-7671
Practice Address - Street 1:379 WALMART DR
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:DE
Practice Address - Zip Code:19934-1365
Practice Address - Country:US
Practice Address - Phone:302-387-4343
Practice Address - Fax:302-538-6790
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0051953208600000X
DEC1-0012808207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD424400100Medicaid
MD084N967FMedicare PIN
G50870Medicare UPIN