Basic Information
Provider Information | |||||||||
NPI: | 1760747430 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VENKATACHALAM | ||||||||
FirstName: | KARTHIKEYAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 102 RIVERVIEW DR STE A | ||||||||
Address2: |   | ||||||||
City: | FLOWOOD | ||||||||
State: | MS | ||||||||
PostalCode: | 392328908 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6019811610 | ||||||||
FaxNumber: | 6013662887 | ||||||||
Practice Location | |||||||||
Address1: | 102 RIVERVIEW DR STE A | ||||||||
Address2: |   | ||||||||
City: | FLOWOOD | ||||||||
State: | MS | ||||||||
PostalCode: | 392328908 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6019811610 | ||||||||
FaxNumber: | 6013662887 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/09/2012 | ||||||||
LastUpdateDate: | 08/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/25/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 30294 | MS | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207RN0300X | 30294 | MS | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 30294 | 01 | MS | STATE LICENSE | OTHER | 52421 | 01 | KY | STATE LICENSE | OTHER |