Healthcare Provider Details

I. General information

NPI: 1992250336
Provider Name (Legal Business Name): VENKATA UDAYAGIRI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2016
Last Update Date: 09/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N GREEN BAY RD
NEENAH WI
54956
US

IV. Provider business mailing address

122 E COLLEGE AVE
APPLETON WI
54911-5794
US

V. Phone/Fax

Practice location:
  • Phone: 920-729-6088
  • Fax: 920-729-6484
Mailing address:
  • Phone: 920-996-3264
  • Fax: 920-830-5970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301109854
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number71496
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: