Healthcare Provider Details

I. General information

NPI: 1659348845
Provider Name (Legal Business Name): SANJAY VASUDEVA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 10/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 EAST BLVD
ELKHART IN
46514-2483
US

IV. Provider business mailing address

4755 AMERITECH DR
SOUTH BEND IN
46628-9120
US

V. Phone/Fax

Practice location:
  • Phone: 574-523-3161
  • Fax:
Mailing address:
  • Phone: 574-271-2558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number01044609
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01044609A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier103221444
Identifier TypeMEDICAID
Identifier StateMI
Identifier Issuer
# 2
Identifier110114090
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerRAIL ROAD MEDICARE
# 3
Identifier200082090
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer
# 4
Identifier000000082213
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerANTHEM
# 5
Identifier014460400
Identifier TypeMEDICAID
Identifier StateFL
Identifier IssuerFlorida Medicaid Provider ID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: