Healthcare Provider Details

I. General information

NPI: 1124213442
Provider Name (Legal Business Name): THILAGAVATHI VENKATACHALAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2007
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 NW 9TH AVE
MIAMI FL
33136-1101
US

IV. Provider business mailing address

1801 NW 9TH AVE
MIAMI FL
33136-1101
US

V. Phone/Fax

Practice location:
  • Phone: 305-355-5000
  • Fax: 305-355-5235
Mailing address:
  • Phone: 305-355-5000
  • Fax: 305-355-5235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberFELMD2021-059
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number69779
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberR9160
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number170785
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: