Provider Demographics
NPI:1255645446
Name:VAITLA, PRADEEP KUMAR (MD)
Entity type:Individual
Prefix:
First Name:PRADEEP KUMAR
Middle Name:
Last Name:VAITLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5065
Mailing Address - Fax:601-984-2962
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5065
Practice Address - Fax:601-984-2962
Is Sole Proprietor?:No
Enumeration Date:2010-07-30
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.206335207RN0300X
MS24433207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS518159YJ5DMedicare PIN