Provider Demographics
NPI:1831137215
Name:VIETLA, BHAVANI DURGA (MD)
Entity Type:Individual
Prefix:MRS
First Name:BHAVANI
Middle Name:DURGA
Last Name:VIETLA
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 1:1 WINDMILL CT
Mailing Address - Street 2:
Mailing Address - City:PLAINSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08536-3146
Mailing Address - Country:US
Mailing Address - Phone:732-297-4272
Mailing Address - Fax:732-297-3785
Practice Address - Street 1:2864 ROUTE 27
Practice Address - Street 2:SUITE D
Practice Address - City:NORTH BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08902-5010
Practice Address - Country:US
Practice Address - Phone:732-297-4272
Practice Address - Fax:732-297-3785
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06986200207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP01130911OtherRAILROAD MEDICARE
NJ0006734Medicaid
NJP01008431OtherRR MEDICARE
NJ0006734Medicaid
NJ180824A02Medicare PIN
NJ055149Medicare ID - Type Unspecified