Provider Demographics
NPI:1043625478
Name:VENKATARAM, AJAY
Entity Type:Individual
Prefix:
First Name:AJAY
Middle Name:
Last Name:VENKATARAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 SUMMIT POINTE DR
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18508
Mailing Address - Country:US
Mailing Address - Phone:570-877-3988
Mailing Address - Fax:
Practice Address - Street 1:1717 S J ST STE 336
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4933
Practice Address - Country:US
Practice Address - Phone:253-426-4101
Practice Address - Fax:253-426-6936
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60715854207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine