Basic Information
| Provider Information | |||||||||
| NPI: | 1144222142 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VENKATAKRISHNA | ||||||||
| FirstName: | KANAKAPURA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 W 22ND ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605231563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305755000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11104 PARKVIEW CIRCLE DR | ||||||||
| Address2: | ENTRANCE 11, SUITE 330 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604943484 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 05/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 35.067919 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | 01045053A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 0310587 | 05 | OH | MEDICAID | 200093260 | 05 | IN | MEDICAID | 100082060 | 05 | IN | MEDICAID | 000000095598 | 01 | IN | BCBS | OTHER |