Provider Demographics
NPI:1659302891
Name:GORANTLA, VENKATESAN R (MD)
Entity Type:Individual
Prefix:
First Name:VENKATESAN
Middle Name:R
Last Name:GORANTLA
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 1:655 W 8TH ST FL CC6
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-6511
Mailing Address - Country:US
Mailing Address - Phone:513-310-2392
Mailing Address - Fax:
Practice Address - Street 1:655 W 8TH ST FL CC6
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:513-310-2392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1026282080N0001X
GA0597292080N0001X
OH35062316208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000593692OtherANTHEM PROVIDER NUMBER
IN200523260Medicaid
IN000000593692OtherANTHEM PROVIDER NUMBER