MEDICARE: DR. TEJASWI VENKATA MUDIGONDA 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	207N00000X	Dermatology Physician	68967	TN
2	207ND0900X	Dermatopathology Physician	68967	TN
3	207NS0135X	Procedural Dermatology Physician	68967	TN
4	207ND0101X	MOHS-Micrographic Surgery Physician	68967	TN
5	207ND0101X	MOHS-Micrographic Surgery Physician	73704	AZ

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	:	1891143277
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TEJASWI VENKATA MUDIGONDA M.D.

Provider Business Mailing Address
First Line	:	9097 W POST RD STE 100
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-2417
Country	:	US
Telephone Number	:	928-854-5400
Fax Number	:	928-216-4165

Provider Business Practice Location Address
First Line	:	1801 MESQUITE AVE
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5668
Country	:	US
Telephone Number	:	928-854-5400
Fax Number	:	928-216-4165

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

Provider Enumeration Date	:	05/26/2016
Last Update Date	:	03/19/2026

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