Healthcare Provider Details

I. General information

NPI: 1760821714
Provider Name (Legal Business Name): VENKATA R GHANTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2013
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 E BROADWAY
COLUMBIA MO
65201-5844
US

IV. Provider business mailing address

1600 EAST BROADWAY
COLUMBIA MO
65201-5844
US

V. Phone/Fax

Practice location:
  • Phone: 573-815-8000
  • Fax: 573-815-8556
Mailing address:
  • Phone: 573-815-8000
  • Fax: 573-815-8556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberQ8891
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2018000532
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2018000532
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: