Provider Demographics
NPI:1174565469
Name:VEDANARAYANAN, VETTAIKORUMAKANKAV V (MD)
Entity type:Individual
Prefix:MR
First Name:VETTAIKORUMAKANKAV
Middle Name:V
Last Name:VEDANARAYANAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:7731 OLD CANTON RD STE B
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6115
Mailing Address - Country:US
Mailing Address - Phone:601-499-0935
Mailing Address - Fax:601-499-0936
Practice Address - Street 1:401 BAPTIST DR STE 301
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-2012
Practice Address - Country:US
Practice Address - Phone:601-984-5210
Practice Address - Fax:601-499-0936
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12953207ZP0102X, 208000000X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP01234014OtherRAILROAD MEDICARE PTAN
LA1982156Medicaid
AL155977Medicaid
MSPTAN P00462340OtherRR MEDICARE
MS00019355Medicaid
MS302I137036Medicare PIN
MS3700000066Medicare ID - Type UnspecifiedMISSISSIPPI MEDICARE
MS00019355Medicaid