Provider Demographics
NPI:1467411140
Name:EVANI, VENKATA (MD)
Entity Type:Individual
Prefix:
First Name:VENKATA
Middle Name:
Last Name:EVANI
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 1:4250 E CAMELBACK RD
Mailing Address - Street 2:SUITE K200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-8388
Mailing Address - Country:US
Mailing Address - Phone:602-977-0136
Mailing Address - Fax:602-977-0758
Practice Address - Street 1:4250 E CAMELBACK RD
Practice Address - Street 2:SUITE K200
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-8388
Practice Address - Country:US
Practice Address - Phone:602-977-0136
Practice Address - Fax:602-977-0758
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20688208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ103317Medicaid
F22977Medicare UPIN
AZZ63885Medicare PIN