Provider Demographics
NPI:1831444553
Name:PENDYALA, VENKATA SUSRUT (MD)
Entity type:Individual
Prefix:DR
First Name:VENKATA
Middle Name:SUSRUT
Last Name:PENDYALA
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 1:550 GAGE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-9532
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:509-627-2983
Practice Address - Street 1:1100 GOETHALS DR STE F
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3301
Practice Address - Country:US
Practice Address - Phone:509-942-3272
Practice Address - Fax:509-942-3273
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-138524207R00000X
WAMD61171799207R00000X, 207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036138524Medicaid
IL036138524Medicaid