Basic Information
| Provider Information | |||||||||
| NPI: | 1346598943 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAJRALA | ||||||||
| FirstName: | VENKATA | ||||||||
| MiddleName: | SUBBA REDDY | ||||||||
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| Credential: | M. D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3170 KETTERING BLVD BLDG B3 | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379913186 | ||||||||
| FaxNumber: | 9372239811 | ||||||||
| Practice Location | |||||||||
| Address1: | 3130 N COUNTY ROAD 25A | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453731337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374404466 | ||||||||
| FaxNumber: | 9374404470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2012 | ||||||||
| LastUpdateDate: | 04/10/2018 | ||||||||
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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 | 35.126134 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.