Provider Demographics
NPI:1760487979
Name:VENKATESH, LATHA (MD)
Entity type:Individual
Prefix:
First Name:LATHA
Middle Name:
Last Name:VENKATESH
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 1:3170 KETTERING BLVD BLDG B2
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:
Practice Address - Street 1:6611 CLYO RD STE D
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-2785
Practice Address - Country:US
Practice Address - Phone:937-208-7350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-6413207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2239956Medicaid
OHH02981Medicare UPIN
OH0889743Medicare PIN
OH0889745Medicare PIN
OH2239956Medicaid
OH4015079Medicare PIN
OHH200722Medicare PIN