MEDICARE: LATHA VENKATESH 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	207R00000X	Internal Medicine Physician	35-07-6413	OH

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	:	1760487979
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATHA VENKATESH M.D.

Provider Business Mailing Address
First Line	:	3170 KETTERING BLVD BLDG B2
Second Line	:
City	:	MORAINE
State	:	OH
Zip	:	45439-1924
Country	:	US
Telephone Number	:	937-991-3188
Fax Number	:

Provider Business Practice Location Address
First Line	:	6611 CLYO RD STE D
Second Line	:
City	:	CENTERVILLE
State	:	OH
Zip	:	45459-2785
Country	:	US
Telephone Number	:	937-208-7350
Fax Number	:

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

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	03/24/2022

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