Healthcare Provider Details

I. General information

NPI: 1245933357
Provider Name (Legal Business Name): ANANYA VASUDHAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 07/23/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

#15 BYRASANDRA MAIN ROAD JAYANAGAR 1ST BLOCK EAST
BENGALURU KARNATAKA
560011
IN

V. Phone/Fax

Practice location:
  • Phone: 224-727-9829
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberT-5176
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: