Healthcare Provider Details

I. General information

NPI: 1750669214
Provider Name (Legal Business Name): RADHA KRISHNA RAO VEGUNTA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 4TH ST N
FARGO ND
58102-4539
US

IV. Provider business mailing address

820 4TH ST N
FARGO ND
58102-4539
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-6161
  • Fax:
Mailing address:
  • Phone: 701-234-6161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125060362
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number14538
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: