Provider Demographics
NPI:1225158827
Name:KOGANTI, VENKATA R
Entity Type:Individual
Prefix:MR
First Name:VENKATA
Middle Name:R
Last Name:KOGANTI
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 1:4 DANDELION LN
Mailing Address - Street 2:
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733-1474
Mailing Address - Country:US
Mailing Address - Phone:718-250-0060
Mailing Address - Fax:
Practice Address - Street 1:104 DEKALB AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5427
Practice Address - Country:US
Practice Address - Phone:718-250-0060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048288183500000X
NJ21400183500000X
MD13958183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD02311379Medicaid