Provider Demographics
NPI:1992788368
Name:VENUGOPAL, ANNIE (MD)
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:VENUGOPAL
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 1:1705 E 19TH STREET
Mailing Address - Street 2:SUITE 501
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5416
Mailing Address - Country:US
Mailing Address - Phone:918-744-8110
Mailing Address - Fax:918-744-8111
Practice Address - Street 1:1705 E 19TH STREET
Practice Address - Street 2:SUITE 501
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5416
Practice Address - Country:US
Practice Address - Phone:918-744-8110
Practice Address - Fax:918-744-8111
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13326208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100009780AMedicaid
OK100009780AMedicaid