Provider Demographics
NPI:1831546571
Name:VAGVALA, SAIVENKAT H (DO)
Entity type:Individual
Prefix:
First Name:SAIVENKAT
Middle Name:H
Last Name:VAGVALA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:SAI
Other - Middle Name:
Other - Last Name:VAGVALA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1101 WOLF LAKE DR # 100
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-3778
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 WOLF LAKE DR # 100
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-3778
Practice Address - Country:US
Practice Address - Phone:877-324-3310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-23
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI699062085R0202X
WI18315465712085R0202X
MI5101022440390200000X
TXU97912085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100081240Medicaid