Provider Demographics
NPI:1043291321
Name:VONTIVILLU, GAYATHRI S (MD)
Entity type:Individual
Prefix:DR
First Name:GAYATHRI
Middle Name:S
Last Name:VONTIVILLU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 N MACARTHUR BLVD
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75061-2220
Mailing Address - Country:US
Mailing Address - Phone:972-579-8485
Mailing Address - Fax:972-579-3972
Practice Address - Street 1:1901 N MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-2220
Practice Address - Country:US
Practice Address - Phone:972-579-8485
Practice Address - Fax:972-579-3972
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301071781207R00000X
TXN5463207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX217372601Medicaid
TX8CL601OtherBCBSTX
TX8CL601OtherBCBSTX
TX217372601Medicaid
MI0N19100004Medicare PIN
TXP01035231Medicare PIN