Healthcare Provider Details

I. General information

NPI: 1912055237
Provider Name (Legal Business Name): VENKATA MUDDANA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3219 CLIFTON AVE
CINCINNATI OH
45220-3027
US

IV. Provider business mailing address

2801 W KINNICKINNIC RIVER PKWY STE 1080
MILWAUKEE WI
53215-3689
US

V. Phone/Fax

Practice location:
  • Phone: 513-853-9250
  • Fax:
Mailing address:
  • Phone: 414-908-6601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number64125-20
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number35.099991
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: