Provider Demographics
NPI:1578623278
Name:MADHIPATLA, VENU M (MD)
Entity type:Individual
Prefix:
First Name:VENU
Middle Name:M
Last Name:MADHIPATLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:455 PHILIP BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-8768
Mailing Address - Country:US
Mailing Address - Phone:770-962-3642
Mailing Address - Fax:770-962-3643
Practice Address - Street 1:455 PHILIP BLVD STE 140
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8768
Practice Address - Country:US
Practice Address - Phone:770-962-3642
Practice Address - Fax:770-962-3643
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA65559207L00000X, 207RC0200X, 208VP0014X
GA065559207LP2900X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200973980Medicaid
GA003104831NMedicaid
KY7100117730Medicaid
GA003104831AMedicaid
GA202I056420Medicare PIN