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General NPI Number Information
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NPI Number | 1285385401
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Entity Type | Organization
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Legal Business Name | LAKE SUMTER UROLOGY, LLC
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Dates
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Enumeration Date | 01/11/2022
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Last Update Date | 11/22/2023
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Provider Practice Location Address
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Address Line | 808 HIGHWAY 466
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City | LADY LAKE
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State | FL
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Zip | 32159-3918
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Country | US
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Telephone | 352-775-6899
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Fax | 877-319-1879
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Provider Business Mailing Address
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Address Line | 808 HIGHWAY 466
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City | LADY LAKE
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State | FL
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Zip | 32159-3918
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Country | US
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Telephone | 352-775-6899
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Fax | 877-319-1879
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Authorized Official
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Title or Position | OWNER AND AO
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Name | VENKATA MARELLA
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Credential | MD
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Telephone | 352-775-6899
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number |
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License Number State |
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