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General NPI Number Information
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NPI Number | 1750388955
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Entity Type | Individual
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Provider Name | VENKATESWARA R KANUBADDI M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/01/2005
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Last Update Date | 06/18/2013
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Provider Practice Location Address
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Address Line | 2121 LAKE AVE
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City | FORT WAYNE
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State | IN
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Zip | 46805-5100
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Country | US
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Telephone | 260-426-5431
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Fax | 260-460-1383
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Provider Business Mailing Address
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Address Line | 1928 SYCAMORE HILLS DR
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City | FORT WAYNE
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State | IN
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Zip | 46814-9304
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Country | US
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Telephone | 260-625-3540
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Fax |
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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 | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 01028849A
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License Number State | IN
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