Provider Demographics
NPI:1124029335
Name:TALASILA, VENKAT (MD)
Entity Type:Individual
Prefix:
First Name:VENKAT
Middle Name:
Last Name:TALASILA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:VENKAT
Other - Middle Name:
Other - Last Name:TALASILA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2578 MCLEOD DR N
Mailing Address - Street 2:STE 1
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-2859
Mailing Address - Country:US
Mailing Address - Phone:989-799-5440
Mailing Address - Fax:989-799-5651
Practice Address - Street 1:2578 MCLEOD DR N STE 1
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-2859
Practice Address - Country:US
Practice Address - Phone:989-799-5440
Practice Address - Fax:989-799-5651
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301407245174400000X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1942468459Medicaid
MI3117160Medicaid
MI0M08820Medicare ID - Type Unspecified