Provider Demographics
NPI:1619006228
Name:AGUSALA, VASANTHA (MD)
Entity Type:Individual
Prefix:DR
First Name:VASANTHA
Middle Name:
Last Name:AGUSALA
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 1:318 N ALLEGHANEY AVE
Mailing Address - Street 2:SUITE 402
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-5052
Mailing Address - Country:US
Mailing Address - Phone:432-337-2714
Mailing Address - Fax:432-337-2726
Practice Address - Street 1:318 N ALLEGHANEY AVE
Practice Address - Street 2:SUITE 402
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5052
Practice Address - Country:US
Practice Address - Phone:432-337-2714
Practice Address - Fax:432-337-2726
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3962207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00450LMedicare ID - Type Unspecified
TXH12816Medicare UPIN