Provider Demographics
NPI:1396743787
Name:VADAKETH, LEENA (MD)
Entity type:Individual
Prefix:
First Name:LEENA
Middle Name:
Last Name:VADAKETH
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 1:1727 JOCKEYS WAY
Mailing Address - Street 2:
Mailing Address - City:YARDLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19067-3972
Mailing Address - Country:US
Mailing Address - Phone:215-685-3808
Mailing Address - Fax:
Practice Address - Street 1:321 W GIRARD AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19123-1531
Practice Address - Country:US
Practice Address - Phone:215-685-3808
Practice Address - Fax:215-685-3848
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35076495207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2162056Medicaid
OHVA0892271Medicare ID - Type Unspecified
OH2162056Medicaid