Healthcare Provider Details

I. General information

NPI: 1851379408
Provider Name (Legal Business Name): YEDATORE S. VENKATESH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 03/07/2023
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 RICHLAND MEDICAL PARK DR STE 420
COLUMBIA SC
29203-8004
US

IV. Provider business mailing address

PO BOX 743904
ATLANTA GA
30374-3904
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-8050
  • Fax: 803-933-3005
Mailing address:
  • Phone: 803-296-7320
  • Fax: 803-296-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberAL34171
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number34171
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number7326
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number7326
License Number StateNV
# 5
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberAL34171
License Number StateSC
# 6
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number34171
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: