Provider Demographics
NPI:1275093734
Name:VENKATESULU, BHANU PRASAD (MD)
Entity Type:Individual
Prefix:
First Name:BHANU PRASAD
Middle Name:
Last Name:VENKATESULU
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 1:300 HALKET ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213-3108
Mailing Address - Country:US
Mailing Address - Phone:832-275-4272
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:832-275-4272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.0753992085R0001X
PAMD4837912085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1275093734Medicaid