Healthcare Provider Details

I. General information

NPI: 1174565469
Provider Name (Legal Business Name): VETTAIKORUMAKANKAV V VEDANARAYANAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 05/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BAPTIST DR STE 301
MADISON MS
39110-2012
US

IV. Provider business mailing address

7731 OLD CANTON RD STE B
MADISON MS
39110-6115
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5210
  • Fax: 601-499-0936
Mailing address:
  • Phone: 601-499-0935
  • Fax: 601-499-0936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number12953
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12953
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number12953
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: