Provider Demographics
NPI:1679781793
Name:LAKKIMSETTY, VENKATA MOHAN RAJU (MD)
Entity Type:Individual
Prefix:DR
First Name:VENKATA
Middle Name:MOHAN RAJU
Last Name:LAKKIMSETTY
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 1:1 FREEDOM WAY
Mailing Address - Street 2:CHARLIE NORWOOD AUGUSTA VA
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904
Mailing Address - Country:US
Mailing Address - Phone:706-733-0188
Mailing Address - Fax:
Practice Address - Street 1:1 FREEDOM WAY
Practice Address - Street 2:CHARLIE NORWOOD AUGUSTA VA
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904
Practice Address - Country:US
Practice Address - Phone:706-733-0188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA0671382081P2900X
FL1018162081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program