Provider Demographics
NPI:1578851572
Name:TENNETI VENKATA, PAVAN KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:PAVAN
Middle Name:KUMAR
Last Name:TENNETI VENKATA
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 1:13041 N DEL WEBB BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85351
Mailing Address - Country:US
Mailing Address - Phone:480-256-6444
Mailing Address - Fax:623-285-2801
Practice Address - Street 1:13041 N DEL WEBB BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351
Practice Address - Country:US
Practice Address - Phone:480-256-6444
Practice Address - Fax:623-285-2801
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2019-00568207R00000X
FLME156097207RH0003X
AZ49297207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114898300Medicaid
FLGIVEDOtherFL BLUE
FLPK944OtherMEDICARE