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General NPI Number Information
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NPI Number | 1154524148
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Entity Type | Individual
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Provider Name | VIVEKANANDA VARMA DATLA M.D.,
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Gender | Male
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Dates
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Enumeration Date | 06/07/2007
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Last Update Date | 05/18/2022
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Provider Practice Location Address
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Address Line | 2201 LEXINGTON AVE
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City | ASHLAND
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State | KY
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Zip | 41101-2843
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Country | US
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Telephone | 606-408-4000
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Fax | 606-408-6825
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Provider Business Mailing Address
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Address Line | PO BOX 2379
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City | ASHLAND
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State | KY
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Zip | 41105-2379
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Country | US
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Telephone | 606-408-6200
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Fax | 606-408-6612
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number | 43412
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 208M00000X
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Taxonomy Name | Hospitalist Physician
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License Number | 43412
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License Number State | KY
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