Provider Demographics
NPI:1457362162
Name:GUTTA, VEERENDRA K (MD)
Entity Type:Individual
Prefix:
First Name:VEERENDRA
Middle Name:K
Last Name:GUTTA
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 1:1300 W TERRELL AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2820
Mailing Address - Country:US
Mailing Address - Phone:817-820-4906
Mailing Address - Fax:817-820-4906
Practice Address - Street 1:1300 W TERRELL AVE FL 2
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2820
Practice Address - Country:US
Practice Address - Phone:817-820-4906
Practice Address - Fax:817-820-4906
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35088040207R00000X
WV23511207R00000X
TN48029207R00000X, 208M00000X
TXQ0645207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000504253OtherANTHEM BCBS
OH2702025Medicaid
001900399OtherMOUNTAIN STATE BCBS
WV3810006339Medicaid
OH310717085156OtherOHIO MEDICAID CARESOURCE
OH000000204503OtherOH MEDICAID UNISON
OH2702025OtherMOLINA MEDICAID
P00347423OtherRR MEDICARE
I58679Medicare UPIN
OH2702025Medicaid
TX360679YKPWMedicare PIN