Healthcare Provider Details

I. General information

NPI: 1114423878
Provider Name (Legal Business Name): VAIBHAV ACHYUT SURYA BHAMIDIPATI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 08/14/2025
Certification Date: 08/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BLYTHE BLVD
CHARLOTTE NC
28203-5812
US

IV. Provider business mailing address

4448 RED BARN
RICHARDSON TX
75082-2680
US

V. Phone/Fax

Practice location:
  • Phone: 704-381-2000
  • Fax:
Mailing address:
  • Phone: 469-203-9572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberBP10062994
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2025-02800
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: