Healthcare Provider Details

I. General information

NPI: 1760762033
Provider Name (Legal Business Name): VEDANT VAKSHA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2011
Last Update Date: 06/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NESCONSET HWY BLDG 10D
STONY BROOK NY
11790-2553
US

IV. Provider business mailing address

2500 NESCONSET HWY BLDG 10D
STONY BROOK NY
11790-2553
US

V. Phone/Fax

Practice location:
  • Phone: 631-981-2663
  • Fax: 212-203-9223
Mailing address:
  • Phone: 631-981-2663
  • Fax: 212-203-9223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number003891
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: