Provider Demographics
NPI:1962673392
Name:VIDI, VENKATESAN DYANESH (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:VENKATESAN
Middle Name:DYANESH
Last Name:VIDI
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:VENKATESAN
Other - Middle Name:
Other - Last Name:VIDI SEETHARAMIER DYANESH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, MPH
Mailing Address - Street 1:1615 PRECINCT LINE RD STE 103
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-3345
Mailing Address - Country:US
Mailing Address - Phone:181-771-6014
Mailing Address - Fax:
Practice Address - Street 1:1305 AIRPORT FWY STE 424
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-6608
Practice Address - Country:US
Practice Address - Phone:817-510-1060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY273680207R00000X, 207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX441463OtherMEDICARE PTAN
TX3520546Medicaid
TX441467ZQ99Medicare PIN