Provider Demographics
NPI:1265411029
Name:VENKATESH, MANGALA (MD)
Entity type:Individual
Prefix:DR
First Name:MANGALA
Middle Name:
Last Name:VENKATESH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD BLDG B3
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:2300 MIAMI VALLEY DR STE 550
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-1298
Practice Address - Country:US
Practice Address - Phone:937-438-7500
Practice Address - Fax:937-438-7555
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350458912084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0496020Medicaid
OH3160053075G36OtherANTHEM
OH7138684001OtherCIGNA
OHD45891OtherCHOICECARE
OH0520032OtherUNITED HEALTHCARE
OHD45891OtherCHOICECARE
OHVE7282811Medicare ID - Type Unspecified
OH0496020Medicaid
OH130024117Medicare PIN