Healthcare Provider Details

I. General information

NPI: 1427207968
Provider Name (Legal Business Name): VENKAT P TUMMALA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2008
Last Update Date: 07/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2125 CRYSTAL GROVE DR
LAKELAND FL
33801-6875
US

IV. Provider business mailing address

2125 CRYSTAL GROVE DR
LAKELAND FL
33801-6875
US

V. Phone/Fax

Practice location:
  • Phone: 863-688-2334
  • Fax:
Mailing address:
  • Phone: 863-688-2334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberME109603
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME109603
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: