Basic Information
| Provider Information | |||||||||
| NPI: | 1275546038 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AKULA | ||||||||
| FirstName: | VENKATA | ||||||||
| MiddleName: | RAVI SANKARUN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | AKULA | ||||||||
| OtherFirstName: | RAVI | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 571 SAINT JOSEPHS BLVD FL 2 | ||||||||
| Address2: | |||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149013230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072712050 | ||||||||
| FaxNumber: | 6072712099 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 JOHN ROEMMELT DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | HORSEHEADS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148458301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077952892 | ||||||||
| FaxNumber: | 6077952816 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 09/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 229731 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | MD430566 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207UN0901X | 229731 | NY | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 207RC0000X | 229731 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 02462173 | 05 | NY | MEDICAID | 100860936 | 05 | PA | MEDICAID |