Provider Demographics
NPI:1881654945
Name:KONERU, LATA (MD)
Entity Type:Individual
Prefix:DR
First Name:LATA
Middle Name:
Last Name:KONERU
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 1:4218 PENRITH CT
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-8276
Mailing Address - Country:US
Mailing Address - Phone:614-659-0500
Mailing Address - Fax:888-760-4007
Practice Address - Street 1:4218 PENRITH CT
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43016-8276
Practice Address - Country:US
Practice Address - Phone:614-566-5000
Practice Address - Fax:888-760-4007
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35073328207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSP00321OtherMEDICARE GROUP NUMBER
OH2093265Medicaid
OH2093265Medicaid
OHSP00321OtherMEDICARE GROUP NUMBER
OHP00616394Medicare PIN
OH4036571Medicare PIN
OH080169778Medicare PIN