MEDICARE: DR. MANGALA VENKATESH M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	35045891	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	3160053075G36	OTHER	OH	ANTHEM
3	7138684001	OTHER	OH	CIGNA
4	D45891	OTHER	OH	CHOICECARE
5	0520032	OTHER	OH	UNITED HEALTHCARE

General Provider Information

NPI Number	:	1265411029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MANGALA VENKATESH M.D.

Provider Business Mailing Address
First Line	:	3170 KETTERING BLVD BLDG B3
Second Line	:
City	:	MORAINE
State	:	OH
Zip	:	45439-1924
Country	:	US
Telephone Number	:	937-991-3188
Fax Number	:	937-223-9811

Provider Business Practice Location Address
First Line	:	2300 MIAMI VALLEY DR STE 550
Second Line	:
City	:	CENTERVILLE
State	:	OH
Zip	:	45459-1298
Country	:	US
Telephone Number	:	937-438-7500
Fax Number	:	937-438-7555

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2006
Last Update Date	:	10/22/2020

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