Healthcare Provider Details

I. General information

NPI: 1174064414
Provider Name (Legal Business Name): VENKATARAMANAIAH KAMATAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 11/27/2023
Certification Date: 11/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 SAGAMORE PKWY W STE 917
WEST LAFAYETTE IN
47906-1443
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 765-463-0710
  • Fax: 765-463-0711
Mailing address:
  • Phone: 317-528-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0512365A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: