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General NPI Number Information
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NPI Number | 1265411029
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Entity Type | Individual
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Provider Name | MANGALA VENKATESH M.D.
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Gender | Female
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Dates
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Enumeration Date | 01/11/2006
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Last Update Date | 10/22/2020
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Provider Practice Location Address
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Address Line | 2300 MIAMI VALLEY DR STE 550
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City | CENTERVILLE
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State | OH
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Zip | 45459-1298
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Country | US
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Telephone | 937-438-7500
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Fax | 937-438-7555
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Provider Business Mailing Address
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Address Line | 3170 KETTERING BLVD BLDG B3
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City | MORAINE
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State | OH
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Zip | 45439-1924
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Country | US
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Telephone | 937-991-3188
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Fax | 937-223-9811
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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 | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 35045891
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License Number State | OH
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