Provider Demographics
NPI:1720097686
Name:GUDUGUNTLA, VENKATESHAM (MD)
Entity Type:Individual
Prefix:
First Name:VENKATESHAM
Middle Name:
Last Name:GUDUGUNTLA
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 1:2251 N VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:BONHAM
Mailing Address - State:TX
Mailing Address - Zip Code:75418-2011
Mailing Address - Country:US
Mailing Address - Phone:903-583-8212
Mailing Address - Fax:903-583-6709
Practice Address - Street 1:1209 EAST NINTH STREET
Practice Address - Street 2:
Practice Address - City:BONHAM
Practice Address - State:TX
Practice Address - Zip Code:75418
Practice Address - Country:US
Practice Address - Phone:903-583-6617
Practice Address - Fax:903-583-6617
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.09821R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine