Healthcare Provider Details

I. General information

NPI: 1265936827
Provider Name (Legal Business Name): GOUTHAMI RATNA CHENNU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 08/08/2025
Certification Date: 08/08/2025
Deactivation Date: 03/20/2018
Reactivation Date: 03/27/2018

III. Provider practice location address

445 CHARLES H DIMMOCK PKWY STE 100
COLONIAL HEIGHTS VA
23834-2990
US

IV. Provider business mailing address

445 CHARLES H DIMMOCK PKWY STE 100
COLONIAL HEIGHTS VA
23834-2990
US

V. Phone/Fax

Practice location:
  • Phone: 804-520-1764
  • Fax:
Mailing address:
  • Phone: 804-520-1764
  • Fax: 804-616-4221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA1102000
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number0101285139
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number0101285139
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: