Healthcare Provider Details

I. General information

NPI: 1679070569
Provider Name (Legal Business Name): VAMSI KRISHNA VENNAM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12865 POINTE DEL MAR WAY STE 210
DEL MAR CA
92014-3860
US

IV. Provider business mailing address

3835 N FREEWAY BLVD STE 100
SACRAMENTO CA
95834-1954
US

V. Phone/Fax

Practice location:
  • Phone: 855-427-2778
  • Fax:
Mailing address:
  • Phone: 916-576-7900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20A19415
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: