Provider Demographics
NPI:1639159023
Name:VENUGOPAL, PRIYA R (MD)
Entity Type:Individual
Prefix:DR
First Name:PRIYA
Middle Name:R
Last Name:VENUGOPAL
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:PO BOX 92038
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-0101
Mailing Address - Country:US
Mailing Address - Phone:817-749-2001
Mailing Address - Fax:940-483-1568
Practice Address - Street 1:2817 S MAYHILL RD STE 270
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76208-5970
Practice Address - Country:US
Practice Address - Phone:817-749-2001
Practice Address - Fax:817-749-3316
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5600174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0020MLOtherBLUE CROSS BLUE SHIELD
TX0020MLOtherBLUE CROSS BLUE SHIELD
TX00627ZMedicare UPIN
TX8F1343Medicare UPIN
TX8F1343Medicare ID - Type UnspecifiedPROVIDER NUMBER