Provider Demographics
NPI:1154398626
Name:VEDALA, GIRIDHAR (MD)
Entity type:Individual
Prefix:
First Name:GIRIDHAR
Middle Name:
Last Name:VEDALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 MEDICAL CENTER BLVD
Mailing Address - Street 2:200
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2888
Mailing Address - Country:US
Mailing Address - Phone:936-441-9680
Mailing Address - Fax:936-539-9685
Practice Address - Street 1:100 MEDICAL CENTER BLVD
Practice Address - Street 2:200
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2888
Practice Address - Country:US
Practice Address - Phone:936-441-9680
Practice Address - Fax:936-539-9685
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301077406207RC0000X, 207UN0901X
TXP9021207UN0901X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH22350Medicare UPIN