Basic Information
| Provider Information | |||||||||
| NPI: | 1295709269 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANTHA | ||||||||
| FirstName: | VENKAT | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 BAYLOR PLZ | ||||||||
| Address2: | MS 120 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770303411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137987356 | ||||||||
| FaxNumber: | 7137986374 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 BAYLOR PLZ | ||||||||
| Address2: | MS 120 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770303411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137987356 | ||||||||
| FaxNumber: | 7137986374 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 07/17/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | FTL44819 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 001679910 | 05 | PA | MEDICAID |