=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598964603
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VENKAT REDDY MANGUNTA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2007
-----------------------------------------------------
Last Update Date | 01/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 S CEDAR CREST BLVD FL 2
-----------------------------------------------------
City | ALLENTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18103-6202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-402-6164
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 9007
-----------------------------------------------------
City | CHARLOTTESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22906-9007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | MD480482
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 2017030006
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207LC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | 0101244048
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 036171924
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------