1639524192 NPI number — SRINIVAS RAO MYNENI VENKATASATYA DDS, PHD

Table of content: SRINIVAS RAO MYNENI VENKATASATYA DDS, PHD (NPI 1639524192)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639524192 NPI number — SRINIVAS RAO MYNENI VENKATASATYA DDS, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MYNENI VENKATASATYA
Provider First Name:
SRINIVAS RAO
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS, PHD
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:
1639524192
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7 PRESIDENTS DR
Provider Second Line Business Mailing Address:
APT 4B
Provider Business Mailing Address City Name:
PORT JEFFERSON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11777-2055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
108 ROCKLAND HL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STONY BROOK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11794-8703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-632-8739
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/03/2016

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: 1223P0300X , with the licence number:  000063-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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