Healthcare Provider Details

I. General information

NPI: 1417954835
Provider Name (Legal Business Name): LATHA VENKATESH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 02/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 REMINGTON PLZ
RAYMORE MO
64083-8640
US

IV. Provider business mailing address

3801 BLUE PKWY
KANSAS CITY MO
64130-2807
US

V. Phone/Fax

Practice location:
  • Phone: 888-403-1071
  • Fax:
Mailing address:
  • Phone: 816-923-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberR7J41
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: