Provider Demographics
NPI:1558388579
Name:THADAREDDY, VENKAT RAMANA (MD)
Entity Type:Individual
Prefix:
First Name:VENKAT
Middle Name:RAMANA
Last Name:THADAREDDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:6210 E HIGHWAY 290 STE 420
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-1142
Mailing Address - Country:US
Mailing Address - Phone:512-483-9569
Mailing Address - Fax:124-066-2165
Practice Address - Street 1:151 EXCHANGE BLVD STE 150
Practice Address - Street 2:
Practice Address - City:HUTTO
Practice Address - State:TX
Practice Address - Zip Code:78634-5376
Practice Address - Country:US
Practice Address - Phone:979-279-3451
Practice Address - Fax:979-279-5163
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9384207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131090608Medicaid
TX1821185299OtherBRAZOS VALLEY COMMUNITY ACTION AGENCY, INC. - AGENCY NPI
TX67-1974OtherBVCAA, INC. DBA HEARNE CHC - FACILITY MEDICARE NUMBER
TX131090609Medicaid
TX2872434-01OtherBVCAA DBA HEARNE CHC MEDICAID NUMBER
TX131090609Medicaid
TX74-1715140OtherBRAZOS VALLEY COMMUNITY ACTION AGENCY, INC. - EIN
TX1558645333OtherHEARNE COMMUNITY HEALTH CENTER - FACILITY NPI
TX74-1715140OtherBRAZOS VALLEY COMMUNITY ACTION AGENCY, INC. - EIN