Healthcare Provider Details

I. General information

NPI: 1649330184
Provider Name (Legal Business Name): PUDUPAKKAM K. VEDANTHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 02/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700 W VIRGINIA AVE UNIT B
LAKEWOOD CO
80226-3144
US

IV. Provider business mailing address

7700 W VIRGINIA AVE UNIT B
LAKEWOOD CO
80226-3144
US

V. Phone/Fax

Practice location:
  • Phone: 303-238-0471
  • Fax: 303-238-6711
Mailing address:
  • Phone: 303-238-0471
  • Fax: 303-238-6711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number19219
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: