Provider Demographics
NPI:1255380671
Name:ERELLA, VENKATA S (MD)
Entity type:Individual
Prefix:
First Name:VENKATA
Middle Name:S
Last Name:ERELLA
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:PO BOX 201450
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78720
Mailing Address - Country:US
Mailing Address - Phone:512-730-3885
Mailing Address - Fax:512-730-3875
Practice Address - Street 1:11851 JOLLYVILLE RD
Practice Address - Street 2:SUITE#104
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759
Practice Address - Country:US
Practice Address - Phone:512-730-3885
Practice Address - Fax:512-730-3875
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063531A208200000X, 2082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0000000525700OtherANTHEM BLUE SHIELD
IN200863480Medicaid
IN0000000525700OtherANTHEM BLUE SHIELD
I52818Medicare UPIN