Provider Demographics
NPI:1376576066
Name:VANGALA, VENKAT R (MD)
Entity Type:Individual
Prefix:
First Name:VENKAT
Middle Name:R
Last Name:VANGALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8940 SVL BOX
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5132
Mailing Address - Country:US
Mailing Address - Phone:760-946-6000
Mailing Address - Fax:760-242-3502
Practice Address - Street 1:18002 HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2125
Practice Address - Country:US
Practice Address - Phone:706-946-6000
Practice Address - Fax:760-242-3502
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA00A406660208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A406660Medicaid
CA00A406660Medicaid
CAAT170ZMedicare PIN