Healthcare Provider Details

I. General information

NPI: 1205810207
Provider Name (Legal Business Name): SRIDEVI A VEDANTAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 07/28/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10318 COPPER RIDGE DR
FISHERS IN
46040-1465
US

IV. Provider business mailing address

10318 COPPER RIDGE DR
FISHERS IN
46040-1465
US

V. Phone/Fax

Practice location:
  • Phone: 765-965-6566
  • Fax:
Mailing address:
  • Phone: 765-965-6566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01047370A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: