Healthcare Provider Details

I. General information

NPI: 1265847230
Provider Name (Legal Business Name): VENKATA DHARMA TEJA SUGNANAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2014
Last Update Date: 11/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 RIVERSIDE DR STE A204
SALISBURY MD
21801
US

IV. Provider business mailing address

PO BOX 1978
SALISBURY MD
21802-1978
US

V. Phone/Fax

Practice location:
  • Phone: 443-358-6193
  • Fax: 443-358-6197
Mailing address:
  • Phone: 410-749-1015
  • Fax: 410-749-0654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD0084369
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: