Provider Demographics
NPI:1396770947
Name:VENGALIL, MARINA TOMY
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:TOMY
Last Name:VENGALIL
Suffix:
Gender:F
Credentials:
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 360541
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15251-6541
Mailing Address - Country:US
Mailing Address - Phone:972-525-9900
Mailing Address - Fax:469-333-7988
Practice Address - Street 1:601 CLARA BARTON BLVD STE 145
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042-5755
Practice Address - Country:US
Practice Address - Phone:972-560-9400
Practice Address - Fax:972-560-9401
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9693207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143930903Medicaid
TXH34565Medicare UPIN
TX143930903Medicaid