Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204F00000X | Transplant Surgeon | 2020026557 | MO |
N | 204F00000X | Transplant Surgeon | 69614 | WI |
N | 208200000X | Surgeon | 125061738 | IL |
N | 208600000X | Surgeon | 125061738 | IL |
N | 208200000X | Surgeon | 2020026557 | MO |
N | 208600000X | Surgeon | 2020026557 | MO |
N | 208200000X | Surgeon | 69614 | WI |
N | 208600000X | Surgeon | 69614 | WI |
NPI | 1649534231 |
---|---|
Provider Name | Vidyaratna A Fleetwood |
First Address | Madison, WI 53703-3808 |
Second Address | Saint Louis, MO 63104-1016 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/06/2012 |
Last Update Date | 23/03/2021 |