Basic Information
| Provider Information | |||||||||
| NPI: | 1316071079 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAKKALA | ||||||||
| FirstName: | VENKATESHWARA | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 BRIDGE PLZ N | ||||||||
| Address2: | APT# 12 D | ||||||||
| City: | FORT LEE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070245911 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1276 FULTON AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104563402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185901800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207R00000X | 220914 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.