Provider Demographics
NPI:1689656357
Name:BOTLA, VENUGOPAL (MD)
Entity Type:Individual
Prefix:DR
First Name:VENUGOPAL
Middle Name:
Last Name:BOTLA
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 1:1294 S JONES BLVD
Mailing Address - Street 2:SUITE 12
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146
Mailing Address - Country:US
Mailing Address - Phone:702-877-1887
Mailing Address - Fax:702-877-4536
Practice Address - Street 1:1294 S JONES BLVD
Practice Address - Street 2:SUITE 12
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146
Practice Address - Country:US
Practice Address - Phone:702-877-1887
Practice Address - Fax:702-877-4536
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11677207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100508284Medicaid
NVH64744Medicare UPIN