Healthcare Provider Details

I. General information

NPI: 1972599405
Provider Name (Legal Business Name): VASUNDHARA-DEVI VEMULA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VASU VEMULA M.D.

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 5TH AVE STE 100
SAN RAFAEL CA
94901-3252
US

IV. Provider business mailing address

365 BUTTERFIELD RD
SAN ANSELMO CA
94960-1222
US

V. Phone/Fax

Practice location:
  • Phone: 415-994-9906
  • Fax: 415-295-7080
Mailing address:
  • Phone: 415-994-9906
  • Fax: 415-295-7080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC145223
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberC145223
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: