Provider Demographics
NPI:1992250336
Name:UDAYAGIRI, VENKATA
Entity type:Individual
Prefix:
First Name:VENKATA
Middle Name:
Last Name:UDAYAGIRI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 E COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5794
Mailing Address - Country:US
Mailing Address - Phone:920-996-3264
Mailing Address - Fax:920-830-5970
Practice Address - Street 1:333 N GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956
Practice Address - Country:US
Practice Address - Phone:920-729-6088
Practice Address - Fax:920-729-6484
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301109854207Q00000X
WI71496207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine