Provider Demographics
NPI:1912402488
Name:VEDALA, KISHORE (MD)
Entity type:Individual
Prefix:DR
First Name:KISHORE
Middle Name:
Last Name:VEDALA
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 1:3333 BURNET AVE # MLC5018
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-4315
Mailing Address - Fax:
Practice Address - Street 1:2174 N DRUID HILLS RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-3102
Practice Address - Country:US
Practice Address - Phone:404-785-8218
Practice Address - Fax:404-785-4750
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA1007162084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program