Healthcare Provider Details

I. General information

NPI: 1699045641
Provider Name (Legal Business Name): VENKATA YEARVA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2012
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 CLAY ST
DARLINGTON WI
53530-1228
US

IV. Provider business mailing address

208 E ANN ST APT B
DARLINGTON WI
53530-1400
US

V. Phone/Fax

Practice location:
  • Phone: 419-552-5915
  • Fax:
Mailing address:
  • Phone: 419-552-5915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01076716A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2240-320
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: