Healthcare Provider Details

I. General information

NPI: 1629074596
Provider Name (Legal Business Name): INDI VASUDEVA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 10/16/2025
Certification Date: 10/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4218 W LINEBAUGH AVE
TAMPA FL
33624-5241
US

IV. Provider business mailing address

4218 W LINEBAUGH AVE
TAMPA FL
33624-5241
US

V. Phone/Fax

Practice location:
  • Phone: 813-961-6633
  • Fax: 813-961-7733
Mailing address:
  • Phone: 813-269-7555
  • Fax: 813-269-7575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME93153
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberME93153
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: