Provider Demographics
NPI:1801087861
Name:KADA, VENKATA GANGADHAR TILAK (MD)
Entity type:Individual
Prefix:
First Name:VENKATA
Middle Name:GANGADHAR TILAK
Last Name:KADA
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:PO BOX 1239
Mailing Address - Street 2:6500 HOSPITAL DRIVE
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-1239
Mailing Address - Country:US
Mailing Address - Phone:573-629-3400
Mailing Address - Fax:573-629-3414
Practice Address - Street 1:6500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6890
Practice Address - Country:US
Practice Address - Phone:573-629-3400
Practice Address - Fax:573-629-3414
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125053634390200000X
VA0101256401207QG0300X, 207Q00000X
MO2013023689207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine