Provider Demographics
NPI:1902118045
Name:VASUDEVAN, AMBALAPETTA KODAKKAT (MD)
Entity Type:Individual
Prefix:DR
First Name:AMBALAPETTA
Middle Name:KODAKKAT
Last Name:VASUDEVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 SHIPYARD DRIVE
Mailing Address - Street 2:LOT 42
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21613-2460
Mailing Address - Country:US
Mailing Address - Phone:410-221-2959
Mailing Address - Fax:
Practice Address - Street 1:320 SHIPYARD DRIVE
Practice Address - Street 2:LOT 42
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-2460
Practice Address - Country:US
Practice Address - Phone:410-221-2959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD190912084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
F15251Medicare UPIN