Provider Demographics
NPI:1730173485
Name:MANGESHKUMAR, VENKATACHALAM (MD)
Entity type:Individual
Prefix:DR
First Name:VENKATACHALAM
Middle Name:
Last Name:MANGESHKUMAR
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 1:640 E OREGON RD
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543-9202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:640 EAST OREGON ROAD
Practice Address - Street 2:
Practice Address - City:LITITZ
Practice Address - State:PA
Practice Address - Zip Code:17543
Practice Address - Country:US
Practice Address - Phone:717-569-8773
Practice Address - Fax:717-569-8187
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD0611259L207R00000X, 2084N0400X
PAMD061259L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001672400 0003Medicaid
PA0016724000003Medicaid
PA002306Medicare PIN
PA0016724000003Medicaid