Provider Demographics
NPI:1174589832
Name:VASUDEVAN, KANAKA (MD)
Entity type:Individual
Prefix:DR
First Name:KANAKA
Middle Name:
Last Name:VASUDEVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W TYLER AVE
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-4223
Mailing Address - Country:US
Mailing Address - Phone:870-735-1500
Mailing Address - Fax:870-735-5816
Practice Address - Street 1:200 W TYLER AVE
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4223
Practice Address - Country:US
Practice Address - Phone:870-735-1500
Practice Address - Fax:870-735-5816
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR-2699207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR57442Medicare ID - Type Unspecified