Provider Demographics
NPI:1982827671
Name:ROUTHU, VENKATESHWER RAO (MD)
Entity Type:Individual
Prefix:DR
First Name:VENKATESHWER
Middle Name:RAO
Last Name:ROUTHU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:VENKAT
Other - Middle Name:R
Other - Last Name:ROUTHU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:905 WATERFORD LNDG
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-7717
Mailing Address - Country:US
Mailing Address - Phone:770-957-0638
Mailing Address - Fax:
Practice Address - Street 1:450 NORTHSIDE CHEROKEE BLVD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-8015
Practice Address - Country:US
Practice Address - Phone:770-224-1000
Practice Address - Fax:770-224-2451
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000058021207R00000X
IAMD-44995207R00000X
GA045944207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000870416AMedicaid
GA000870416AMedicaid
GA11BDRQRMedicare ID - Type Unspecified