Provider Demographics
NPI:1134349673
Name:VETSA, MADHAVI (MD)
Entity type:Individual
Prefix:
First Name:MADHAVI
Middle Name:
Last Name:VETSA
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 1:3975 OLD REDWOOD HWY STE 152
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1719
Mailing Address - Country:US
Mailing Address - Phone:707-566-3875
Mailing Address - Fax:
Practice Address - Street 1:3975 OLD REDWOOD HWY STE 152
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1719
Practice Address - Country:US
Practice Address - Phone:075-665-8757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA98617207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A986170Medicaid