Provider Demographics
NPI:1871553529
Name:YEDDU, AJAY NEILCHAND I (MD)
Entity type:Individual
Prefix:MR
First Name:AJAY
Middle Name:NEILCHAND
Last Name:YEDDU
Suffix:I
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:AJAY
Other - Middle Name:NEILCHAND
Other - Last Name:YEDDU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:HIGLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85236-0097
Mailing Address - Country:US
Mailing Address - Phone:480-838-1914
Mailing Address - Fax:480-838-9434
Practice Address - Street 1:1410 W GUADALUPE RD
Practice Address - Street 2:BUILDING 4 SUITE 125
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-3003
Practice Address - Country:US
Practice Address - Phone:480-838-1914
Practice Address - Fax:480-838-9434
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34866207L00000X, 208VP0014X
LAMD-15499R207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1423360Medicaid
AZ34866OtherAZ STATE LICENSE
AZ081425Medicaid
AZ34866OtherAZ STATE LICENSE
LA4J039CN67Medicare ID - Type Unspecified
AZ113355Medicare PIN