Provider Demographics
NPI:1972570349
Name:ANANTHRAM, VASUDEV G (MD)
Entity type:Individual
Prefix:
First Name:VASUDEV
Middle Name:G
Last Name:ANANTHRAM
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 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:117 BULIFANTS BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-5712
Practice Address - Country:US
Practice Address - Phone:757-259-9540
Practice Address - Fax:757-259-9547
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101232846207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1972570349Medicaid
VAG01526Medicare UPIN
VA017533R53Medicare PIN