Provider Demographics
NPI:1770861478
Name:DURVASULA, VENKATA SURYA PHANI BHUSHAN (MD)
Entity type:Individual
Prefix:DR
First Name:VENKATA
Middle Name:SURYA PHANI BHUSHAN
Last Name:DURVASULA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:403 W OAK ST STE 105
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-4573
Mailing Address - Country:US
Mailing Address - Phone:870-639-8105
Mailing Address - Fax:870-639-8109
Practice Address - Street 1:403 W OAK ST STE 105
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-4573
Practice Address - Country:US
Practice Address - Phone:870-639-8105
Practice Address - Fax:870-639-8109
Is Sole Proprietor?:No
Enumeration Date:2011-07-28
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-7645207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology