Healthcare Provider Details

I. General information

NPI: 1962486761
Provider Name (Legal Business Name): DR. PRAKASH VAIDY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DR. PRAKASH VAIDYANATHAN

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

379 WALMART DR
CAMDEN DE
19934-1365
US

IV. Provider business mailing address

PO BOX 1040
ELKTON MD
21922-1040
US

V. Phone/Fax

Practice location:
  • Phone: 302-387-4343
  • Fax: 302-538-6790
Mailing address:
  • Phone: 410-398-0590
  • Fax: 443-681-7671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberD0051953
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC1-0012808
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: