Provider Demographics
NPI:1912240698
Name:VASUDEVAN, MUDALODU VEERARAGHAVACHAR (MD)
Entity Type:Individual
Prefix:DR
First Name:MUDALODU
Middle Name:VEERARAGHAVACHAR
Last Name:VASUDEVAN
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 1:164 W INVITAR LN
Mailing Address - Street 2:
Mailing Address - City:MTN HOUSE
Mailing Address - State:CA
Mailing Address - Zip Code:95391-2036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2470 E FLAMINGO RD STE D
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5200
Practice Address - Country:US
Practice Address - Phone:702-544-3849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-01
Last Update Date:2017-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301102270207Q00000X
NV17489207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5315058571OtherPHARMACY LICENSE CONTROLLED SUBSTANCE NUMBER
MI4301102270OtherMEDICAL LICENSE