Provider Demographics
NPI:1659685709
Name:VENKATACHALAM, VANI (MD, FAAP)
Entity type:Individual
Prefix:DR
First Name:VANI
Middle Name:
Last Name:VENKATACHALAM
Suffix:
Gender:F
Credentials:MD, FAAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 TENNYSON PL
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-5358
Mailing Address - Country:US
Mailing Address - Phone:434-228-0388
Mailing Address - Fax:
Practice Address - Street 1:2651 TEXAS DR STE A
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-7016
Practice Address - Country:US
Practice Address - Phone:972-893-1192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-31
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ5116208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101254197OtherLICENSE
TXQ5116OtherLICENSE
TX1518550474Medicaid