Healthcare Provider Details

I. General information

NPI: 1578851572
Provider Name (Legal Business Name): PAVAN KUMAR TENNETI VENKATA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2011
Last Update Date: 08/14/2025
Certification Date: 02/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13041 N DEL WEBB BLVD SUITE 200
SUN CITY AZ
85351
US

IV. Provider business mailing address

13041 N DEL WEBB BLVD SUITE 200
SUN CITY AZ
85351
US

V. Phone/Fax

Practice location:
  • Phone: 623-832-0300
  • Fax: 623-285-2801
Mailing address:
  • Phone: 623-832-0300
  • Fax: 623-285-2801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2019-00568
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberME156097
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number49297
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: