Provider Demographics
NPI:1083690804
Name:BANDA, VENKAT R (MD)
Entity type:Individual
Prefix:
First Name:VENKAT
Middle Name:R
Last Name:BANDA
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 732094
Mailing Address - Street 2:DEPT 235
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-2094
Mailing Address - Country:US
Mailing Address - Phone:225-387-7916
Mailing Address - Fax:225-372-3717
Practice Address - Street 1:3600 FLORIDA BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806
Practice Address - Country:US
Practice Address - Phone:225-387-7070
Practice Address - Fax:225-387-7700
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11275R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP00294988OtherRAIL ROAD MEDICARE
LA1661856Medicaid
LA1083690804OtherNPI
LA5W427Medicare PIN
LAP00294988OtherRAIL ROAD MEDICARE