Basic Information
Provider Information | |||||||||
NPI: | 1457362162 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUTTA | ||||||||
FirstName: | VEERENDRA | ||||||||
MiddleName: | K. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1300 W TERRELL AVE FL 2 | ||||||||
Address2: |   | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761042820 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8178204906 | ||||||||
FaxNumber: | 8178204906 | ||||||||
Practice Location | |||||||||
Address1: | 1300 W TERRELL AVE FL 2 | ||||||||
Address2: |   | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761042820 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8178204906 | ||||||||
FaxNumber: | 8178204906 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/10/2006 | ||||||||
LastUpdateDate: | 09/12/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35088040 | OH | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 23511 | WV | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 48029 | TN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 48029 | TN | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207R00000X | Q0645 | TX | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 000000504253 | 01 |   | ANTHEM BCBS | OTHER | 2702025 | 05 | OH |   | MEDICAID | 001900399 | 01 |   | MOUNTAIN STATE BCBS | OTHER | 3810006339 | 05 | WV |   | MEDICAID | 310717085156 | 01 | OH | OHIO MEDICAID CARESOURCE | OTHER | 000000204503 | 01 | OH | OH MEDICAID UNISON | OTHER | 2702025 | 01 | OH | MOLINA MEDICAID | OTHER | P00347423 | 01 |   | RR MEDICARE | OTHER |