Provider Demographics
NPI:1851379408
Name:VENKATESH, YEDATORE S (MD)
Entity Type:Individual
Prefix:
First Name:YEDATORE
Middle Name:S
Last Name:VENKATESH
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:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:8 RICHLAND MEDICAL PARK DR STE 420
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-8004
Practice Address - Country:US
Practice Address - Phone:803-434-8050
Practice Address - Fax:803-933-3005
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC341712084P0800X, 2084N0400X
NV73262084N0600X, 2084N0400X
SCAL341712084N0600X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC341712Medicaid
NV100500484Medicaid
NV100500484Medicaid
NVBV2957605OtherDEA
NVF80489Medicare UPIN
NVBV2957605OtherDEA
F80489Medicare UPIN
AA81919482Medicare PIN