MEDICARE: DR. PRIYA R VENUGOPAL 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	174400000X	Specialist	L5600	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0020ML	OTHER	TX	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1639159023
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PRIYA R VENUGOPAL M.D.

Provider Business Mailing Address
First Line	:	PO BOX 92038
Second Line	:
City	:	SOUTHLAKE
State	:	TX
Zip	:	76092-0101
Country	:	US
Telephone Number	:	817-749-2001
Fax Number	:	940-483-1568

Provider Business Practice Location Address
First Line	:	2817 S MAYHILL RD STE 270
Second Line	:
City	:	DENTON
State	:	TX
Zip	:	76208-5970
Country	:	US
Telephone Number	:	817-749-2001
Fax Number	:	817-749-3316

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

Provider Enumeration Date	:	01/20/2006
Last Update Date	:	03/07/2018

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