Provider Demographics
NPI:1164525952
Name:CHALASANI, VENKATA K (MD)
Entity Type:Individual
Prefix:
First Name:VENKATA
Middle Name:K
Last Name:CHALASANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 SAINT CLAIR AVE
Mailing Address - Street 2:JTDM FAMILY PRACTICE, LLC
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-2400
Mailing Address - Country:US
Mailing Address - Phone:419-394-3387
Mailing Address - Fax:419-738-4601
Practice Address - Street 1:812 REDSKIN TRL STE A
Practice Address - Street 2:WAPAKONETA PRIMARY CARE
Practice Address - City:WAPAKONETA
Practice Address - State:OH
Practice Address - Zip Code:45895-8545
Practice Address - Country:US
Practice Address - Phone:419-738-4445
Practice Address - Fax:419-738-4601
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35074822207R00000X, 207R00000X, 207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH280550OtherMEDICARE INDIVIDUAL PTAN
OH0705982OtherMEDICAID LEGACY
OH9934723OtherMEDICARE GROUP PTAN
OH1356772255OtherGROUP NPI -WAPAKONETA PRIMARY CARE
OH2090115Medicaid