Healthcare Provider Details

I. General information

NPI: 1225093719
Provider Name (Legal Business Name): VENU GOPAL KODURI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 05/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 MEADE PARKWAY
SUFFOLK VA
23434-4259
US

IV. Provider business mailing address

2000 MEADE PARKWAY
SUFFOLK VA
23434-4259
US

V. Phone/Fax

Practice location:
  • Phone: 757-539-0251
  • Fax: 757-923-9626
Mailing address:
  • Phone: 757-539-0251
  • Fax: 757-923-9610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number0101049408
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: