Provider Demographics
NPI:1750423042
Name:MANDAVA, VENKATESWARA RAO (MD)
Entity type:Individual
Prefix:DR
First Name:VENKATESWARA
Middle Name:RAO
Last Name:MANDAVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MANDAVA
Other - Middle Name:VENKATESWARA
Other - Last Name:RAO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6632 CORINA CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-4036
Mailing Address - Country:US
Mailing Address - Phone:410-531-2587
Mailing Address - Fax:410-531-2587
Practice Address - Street 1:6632 CORINA CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-4036
Practice Address - Country:US
Practice Address - Phone:410-531-2587
Practice Address - Fax:410-531-2587
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD21136207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC04194105Medicaid
DCMA519683Medicare ID - Type Unspecified
MDB67021Medicare UPIN