Provider Demographics
NPI:1972511590
Name:DEVINENI, VENKATA R (MD)
Entity Type:Individual
Prefix:DR
First Name:VENKATA
Middle Name:R
Last Name:DEVINENI
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 1:2260 BARNBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-3130
Mailing Address - Country:US
Mailing Address - Phone:314-344-6090
Mailing Address - Fax:
Practice Address - Street 1:12303 DE PAUL DR
Practice Address - Street 2:DEPT. OF RADIATION ONCOLOGY
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2512
Practice Address - Country:US
Practice Address - Phone:314-344-6090
Practice Address - Fax:314-344-6093
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR92452085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO206831711Medicaid
MO001012002Medicare ID - Type Unspecified
MOP00226438Medicare ID - Type UnspecifiedMEDICARE RAILROAD
MO206831711Medicaid