Basic Information
Provider Information
NPI: 1033559604
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CHINNAKOTLA
FirstName: VENKATA SAI BHAVANA
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1 HOSPITAL DR
Address2: MA427, DC043.00
City: COLUMBIA
State: MO
PostalCode: 652120001
CountryCode: US
TelephoneNumber: 5738845230
FaxNumber: 5738843037
Practice Location
Address1: 1 HOSPITAL DR
Address2: MA427A, DC043.00
City: COLUMBIA
State: MO
PostalCode: 652120001
CountryCode: US
TelephoneNumber: 5738845230
FaxNumber: 5738843037
Other Information
ProviderEnumerationDate: 06/27/2013
LastUpdateDate: 10/21/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X2013018525MOY Allopathic & Osteopathic PhysiciansInternal Medicine 

No ID Information.


Home