Provider Demographics
NPI:1649330184
Name:VEDANTHAN, PUDUPAKKAM K (MD)
Entity type:Individual
Prefix:
First Name:PUDUPAKKAM
Middle Name:K
Last Name:VEDANTHAN
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 1:7700 W VIRGINIA AVE
Mailing Address - Street 2:UNIT B
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80226-3144
Mailing Address - Country:US
Mailing Address - Phone:303-238-0471
Mailing Address - Fax:303-238-6711
Practice Address - Street 1:7700 W VIRGINIA AVE
Practice Address - Street 2:UNIT B
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80226-3144
Practice Address - Country:US
Practice Address - Phone:303-238-0471
Practice Address - Fax:303-238-6711
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO19219207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01192194Medicaid
COE60181Medicare UPIN
COC481188Medicare PIN