Provider Demographics
NPI:1154421303
Name:VEERULA, GIRIDHAR RAO
Entity type:Individual
Prefix:
First Name:GIRIDHAR
Middle Name:RAO
Last Name:VEERULA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3919 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6811
Mailing Address - Country:US
Mailing Address - Phone:260-436-7722
Mailing Address - Fax:260-459-0012
Practice Address - Street 1:3919 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6811
Practice Address - Country:US
Practice Address - Phone:260-436-7722
Practice Address - Fax:260-459-0012
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043132174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INF13690Medicare UPIN