Provider Demographics
NPI:1780604660
Name:VASUDEVAN, JAYAN (MBBS,ABP)
Entity type:Individual
Prefix:
First Name:JAYAN
Middle Name:
Last Name:VASUDEVAN
Suffix:
Gender:M
Credentials:MBBS,ABP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16602 CAPITOL PLZ APT 3
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68118-4014
Mailing Address - Country:US
Mailing Address - Phone:402-547-6907
Mailing Address - Fax:
Practice Address - Street 1:601 N 30TH ST.
Practice Address - Street 2:SUITE 6820
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131
Practice Address - Country:US
Practice Address - Phone:402-280-4580
Practice Address - Fax:402-280-4159
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE23006208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47073897408Medicaid
NE47073897408Medicaid