1619222411 NPI number — DR. PREETHI GONDI KAMMA VENKATESH M.D

Table of content: ANTHONY MAURICE PINNER P.A-C (NPI 1104856574)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619222411 NPI number — DR. PREETHI GONDI KAMMA VENKATESH M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONDI KAMMA VENKATESH
Provider First Name:
PREETHI
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
F

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:
1619222411
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
86 W UNDERWOOD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32806-1110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-912-3648
Provider Business Mailing Address Fax Number:
321-841-4085

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
86 W UNDERWOOD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32806-1110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-912-3648
Provider Business Practice Location Address Fax Number:
321-841-4085
Provider Enumeration Date:
07/17/2012

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:  57.020758 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2083P0011X , with the licence number: ME121841 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: ME121841 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 021175600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".