Healthcare Provider Details

I. General information

NPI: 1891143277
Provider Name (Legal Business Name): TEJASWI VENKATA MUDIGONDA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 MESQUITE AVE
LAKE HAVASU CITY AZ
86403-5668
US

IV. Provider business mailing address

9097 W POST RD STE 100
LAS VEGAS NV
89148-2417
US

V. Phone/Fax

Practice location:
  • Phone: 928-854-5400
  • Fax: 928-216-4165
Mailing address:
  • Phone: 928-854-5400
  • Fax: 928-216-4165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number73704
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number68967
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number68967
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number68967
License Number StateTN
# 5
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number68967
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: