Provider Demographics
NPI:1346332640
Name:VELLANKI, LATHA SREE (MD)
Entity type:Individual
Prefix:
First Name:LATHA
Middle Name:SREE
Last Name:VELLANKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 RANCH ROAD 2222, BUILDING 1, STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730
Mailing Address - Country:US
Mailing Address - Phone:512-628-0465
Mailing Address - Fax:512-233-2711
Practice Address - Street 1:6648 E CARONDELET DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-2119
Practice Address - Country:US
Practice Address - Phone:520-886-8151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8071207N00000X
AZ75825207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0052700Medicaid
MT070017373OtherRAILROAD MEDICARE
MT000092195OtherBLUE CROSS BLUE SHIELD
MT000092195OtherBLUE CROSS BLUE SHIELD
MT070017373OtherRAILROAD MEDICARE