Healthcare Provider Details

I. General information

NPI: 1780316109
Provider Name (Legal Business Name): VISHNU TEJA OBULAREDDY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2022
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 N 25TH ST
RICHMOND VA
23223-6539
US

IV. Provider business mailing address

719 N 25TH ST
RICHMOND VA
23223-6539
US

V. Phone/Fax

Practice location:
  • Phone: 267-312-7967
  • Fax:
Mailing address:
  • Phone: 267-312-7967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401418054
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: