Healthcare Provider Details

I. General information

NPI: 1144924481
Provider Name (Legal Business Name): VENKATA VISWAJIT MACHA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 GRAND CONCOURSE
BRONX NY
10457-7679
US

IV. Provider business mailing address

656 SAINT NICHOLAS AVE APT 53
NEW YORK NY
10030-1065
US

V. Phone/Fax

Practice location:
  • Phone: 718-960-1234
  • Fax: 718-960-2055
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: