MEDICARE: DR. VENKATA SURYA PHANI BHUSHAN DURVASULA 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	E-7645	AR

General Provider Information

NPI Number	:	1770861478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VENKATA SURYA PHANI BHUSHAN DURVASULA M.D.

Provider Business Mailing Address
First Line	:	403 W OAK ST STE 105
Second Line	:
City	:	EL DORADO
State	:	AR
Zip	:	71730-4573
Country	:	US
Telephone Number	:	870-639-8105
Fax Number	:	870-639-8109

Provider Business Practice Location Address
First Line	:	403 W OAK ST STE 105
Second Line	:
City	:	EL DORADO
State	:	AR
Zip	:	71730-4573
Country	:	US
Telephone Number	:	870-639-8105
Fax Number	:	870-639-8109

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

Provider Enumeration Date	:	07/28/2011
Last Update Date	:	09/21/2022

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