Provider Demographics
NPI:1053604827
Name:KATHARIGUPPA VENKATARAM M.D. P.A.
Entity type:Organization
Organization Name:KATHARIGUPPA VENKATARAM M.D. P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHARIGUPPA
Authorized Official - Middle Name:
Authorized Official - Last Name:VENKATARAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-949-4991
Mailing Address - Street 1:208 CRYSTAL GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-6460
Mailing Address - Country:US
Mailing Address - Phone:813-949-4991
Mailing Address - Fax:813-949-4986
Practice Address - Street 1:208 CRYSTAL GROVE BLVD
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-6460
Practice Address - Country:US
Practice Address - Phone:813-949-4991
Practice Address - Fax:813-949-4986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-26
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73717207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260523600Medicaid
FLG83564Medicare UPIN
FLE0150AMedicare PIN