1578851572 NPI number — PAVAN KUMAR TENNETI VENKATA MD

Table of content: PAVAN KUMAR TENNETI VENKATA MD (NPI 1578851572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578851572 NPI number — PAVAN KUMAR TENNETI VENKATA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TENNETI VENKATA
Provider First Name:
PAVAN
Provider Middle Name:
KUMAR
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578851572
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13041 N DEL WEBB BLVD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
SUN CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-256-6444
Provider Business Mailing Address Fax Number:
623-285-2801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13041 N DEL WEBB BLVD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
SUN CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-256-6444
Provider Business Practice Location Address Fax Number:
623-285-2801
Provider Enumeration Date:
07/12/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  2019-00568 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X , with the licence number: ME156097 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X , with the licence number: 49297 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 114898300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: GIVED . This is a "FL BLUE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: PK944 . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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