Provider Demographics
NPI:1124235221
Name:PATHY, VENKATACHALA (MD)
Entity type:Individual
Prefix:
First Name:VENKATACHALA
Middle Name:
Last Name:PATHY
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 1:1874 PELHAM PKWY SOUTH
Mailing Address - Street 2:SUITE LM
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-3733
Mailing Address - Country:US
Mailing Address - Phone:718-931-8500
Mailing Address - Fax:718-931-0823
Practice Address - Street 1:1874 PELHAM PKWY SOUTH
Practice Address - Street 2:SUITE LM
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-3733
Practice Address - Country:US
Practice Address - Phone:718-931-8500
Practice Address - Fax:718-931-0823
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114601207R00000X, 207RC0000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Not Answered207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00424575Medicaid
NYA63904Medicare UPIN
NY703061Medicare ID - Type Unspecified