Provider Demographics
NPI:1447392527
Name:DURVASULA, VISWA B (MD)
Entity Type:Individual
Prefix:
First Name:VISWA
Middle Name:B
Last Name:DURVASULA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:982 STONEBRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-6027
Mailing Address - Country:US
Mailing Address - Phone:615-902-7461
Mailing Address - Fax:
Practice Address - Street 1:225 NORTH WILLOW AVENUE
Practice Address - Street 2:SUITE NUMBER 1
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2335
Practice Address - Country:US
Practice Address - Phone:931-372-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD00000200372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNG75880Medicare UPIN
TN3826519Medicare ID - Type Unspecified