Provider Demographics
NPI:1043470552
Name:VASUDEVAN, PRASANNA (MD)
Entity type:Individual
Prefix:
First Name:PRASANNA
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 1:990 STEWART AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4822
Mailing Address - Country:US
Mailing Address - Phone:516-222-2022
Mailing Address - Fax:516-222-8475
Practice Address - Street 1:990 STEWART AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4822
Practice Address - Country:US
Practice Address - Phone:516-222-2022
Practice Address - Fax:516-222-8475
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA25945255390200000X
OK2697782085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program