Provider Demographics
NPI:1154903383
Name:DAMISETTI, VENKATESWARARAO
Entity type:Individual
Prefix:
First Name:VENKATESWARARAO
Middle Name:
Last Name:DAMISETTI
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 1:1371 SEABURY AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-3651
Mailing Address - Country:US
Mailing Address - Phone:718-618-0401
Mailing Address - Fax:
Practice Address - Street 1:2015 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-4303
Practice Address - Country:US
Practice Address - Phone:718-299-7295
Practice Address - Fax:718-299-6797
Is Sole Proprietor?:No
Enumeration Date:2021-04-27
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF310234363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health