Provider Demographics
NPI:1356317648
Name:VENKATESH, GOVINDARAJAN (MD)
Entity type:Individual
Prefix:DR
First Name:GOVINDARAJAN
Middle Name:
Last Name:VENKATESH
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 2876
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-2876
Mailing Address - Country:US
Mailing Address - Phone:229-502-9681
Mailing Address - Fax:229-891-9130
Practice Address - Street 1:1 SWEET BAY CT STE A
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6713
Practice Address - Country:US
Practice Address - Phone:229-502-9685
Practice Address - Fax:229-890-0055
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA63143207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003171683Medicaid
PA0019427010001Medicaid
PA06007114OtherRR MEDICARE PIN
NY02379248Medicaid
PACC9269OtherRR MEDICARE GROUP
PA067661N8VMedicare PIN
NY02379248Medicaid