Basic Information
| Provider Information | |||||||||
| NPI: | 1265793897 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VASUDEVAN | ||||||||
| FirstName: | KEON | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7450 ALBERT RD | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | BRANDYWINE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206133035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018882233 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7450 ALBERT RD | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | BRANDYWINE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206133035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018882233 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2012 | ||||||||
| LastUpdateDate: | 09/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | VA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | D79802 | MD | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.