Provider Demographics
NPI:1225093719
Name:KODURI, VENU GOPAL (MD)
Entity Type:Individual
Prefix:
First Name:VENU
Middle Name:GOPAL
Last Name:KODURI
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 1:2000 MEADE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-4259
Mailing Address - Country:US
Mailing Address - Phone:757-539-0251
Mailing Address - Fax:757-923-9610
Practice Address - Street 1:2000 MEADE PARKWAY
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4259
Practice Address - Country:US
Practice Address - Phone:757-539-0251
Practice Address - Fax:757-923-9626
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101049408207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6075738Medicaid
VA100005800OtherRAILROAD MEDICARE
NC890682TMedicaid
F54839Medicare UPIN
VA110004816Medicare PIN