Provider Demographics
NPI:1891138830
Name:BODA ESWARA, VENKATASAI P (MD)
Entity Type:Individual
Prefix:
First Name:VENKATASAI
Middle Name:P
Last Name:BODA ESWARA
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 1:1501 KINGS HWY
Mailing Address - Street 2:INTERNAL MEDICINE
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-813-2528
Mailing Address - Fax:
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:INTERNAL MEDICINE
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-813-2528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-09
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA303124207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program