Healthcare Provider Details

I. General information

NPI: 1164316063
Provider Name (Legal Business Name): VENKATA SATYA DURGA SLN SRAVAN GUDIPATI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2025
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E WAYNE ST APT 212
EDMOND OK
73034-5138
US

IV. Provider business mailing address

900 E WAYNE ST APT 212
EDMOND OK
73034-5138
US

V. Phone/Fax

Practice location:
  • Phone: 872-275-6514
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: