Provider Demographics
NPI:1437111697
Name:THOTA, VENKAT (MD)
Entity Type:Individual
Prefix:
First Name:VENKAT
Middle Name:
Last Name:THOTA
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 1:1518 10TH ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-4405
Mailing Address - Country:US
Mailing Address - Phone:940-723-6400
Mailing Address - Fax:
Practice Address - Street 1:1518 10TH ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-4405
Practice Address - Country:US
Practice Address - Phone:940-723-6400
Practice Address - Fax:940-723-6403
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6362207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX040292702Medicaid
TX040292702Medicaid