Healthcare Provider Details

I. General information

NPI: 1235633868
Provider Name (Legal Business Name): SRIKANTH VEDACHALAM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 BURNET AVE
CINCINNATI OH
45229-3019
US

IV. Provider business mailing address

PO BOX 636256
CINCINNATI OH
45263-6256
US

V. Phone/Fax

Practice location:
  • Phone: 513-558-4831
  • Fax: 513-558-4858
Mailing address:
  • Phone: 513-585-6200
  • Fax: 513-245-3672

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 TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number036168366
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number34.014386
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036168366
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number02006305A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: