Healthcare Provider Details

I. General information

NPI: 1659151579
Provider Name (Legal Business Name): VENKATA AKHIL VALLURI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2023
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 E MCDOWELL RD
PHOENIX AZ
85006-2612
US

IV. Provider business mailing address

12443 N 28TH DR APT L31
PHOENIX AZ
85029-2481
US

V. Phone/Fax

Practice location:
  • Phone: 602-839-2000
  • Fax:
Mailing address:
  • Phone: 706-814-0966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberR81243
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number15822
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: