Provider Demographics
NPI:1063417319
Name:GUTTA, VENKATAIAH (MD)
Entity type:Individual
Prefix:DR
First Name:VENKATAIAH
Middle Name:
Last Name:GUTTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4
Mailing Address - Street 2:
Mailing Address - City:GAFFNEY
Mailing Address - State:SC
Mailing Address - Zip Code:29342-0004
Mailing Address - Country:US
Mailing Address - Phone:864-487-5124
Mailing Address - Fax:864-487-5125
Practice Address - Street 1:140 4TH AVE
Practice Address - Street 2:
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29340-4726
Practice Address - Country:US
Practice Address - Phone:864-487-5124
Practice Address - Fax:864-487-5125
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2007-10-11
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
SC9480173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC094800Medicaid
SCB91475Medicare PIN