=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407115181
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VENUGOPAL KOMAKULA M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2012
-----------------------------------------------------
Last Update Date | 05/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7798 DISCOVERY DR
-----------------------------------------------------
City | WEST CHESTER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45069-7745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-475-7500
-----------------------------------------------------
Fax | 513-475-7501
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2830 VICTORY PKWY
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45206-1785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-245-3072
-----------------------------------------------------
Fax | 513-585-5511
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QS1201X
-----------------------------------------------------
Taxonomy Name | Sleep Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | MD176686
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RS0012X
-----------------------------------------------------
Taxonomy Name | Sleep Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 35139972
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------