Healthcare Provider Details

I. General information

NPI: 1083095061
Provider Name (Legal Business Name): ASHWIN VENKATARAMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2015
Last Update Date: 05/19/2022
Certification Date: 05/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 N SAINT PAUL ST STE 3100
DALLAS TX
75201-3923
US

IV. Provider business mailing address

941 E PARK ROW DR
ARLINGTON TX
76010-4508
US

V. Phone/Fax

Practice location:
  • Phone: 616-229-2935
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125067597
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR6125
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: