Provider Demographics
NPI:1154524148
Name:DATLA, VIVEKANANDA VARMA (MD,)
Entity type:Individual
Prefix:
First Name:VIVEKANANDA
Middle Name:VARMA
Last Name:DATLA
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 2379
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-2379
Mailing Address - Country:US
Mailing Address - Phone:606-408-6200
Mailing Address - Fax:606-408-6612
Practice Address - Street 1:2201 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2843
Practice Address - Country:US
Practice Address - Phone:606-408-4000
Practice Address - Fax:606-408-6825
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY43412207QA0505X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3066524Medicaid
KY7100129360Medicaid
KYP400022836Medicare PIN