MEDICARE: DR. RADHA VINNAKOTA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician	NJMA30649	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184718306
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RADHA VINNAKOTA M.D.

Provider Business Mailing Address
First Line	:	6 RAVINN LN
Second Line	:
City	:	WARREN
State	:	NJ
Zip	:	07059-5572
Country	:	US
Telephone Number	:	908-753-2662
Fax Number	:	908-753-2633

Provider Business Practice Location Address
First Line	:	2013 PARK AVE
Second Line	:
City	:	SOUTH PLAINFIELD
State	:	NJ
Zip	:	07080-5401
Country	:	US
Telephone Number	:	908-753-2662
Fax Number	:	908-753-2633

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	10/04/2019

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