Provider Demographics
NPI:1649530551
Name:VEMURI, RADHIKA
Entity type:Individual
Prefix:
First Name:RADHIKA
Middle Name:
Last Name:VEMURI
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 1:5023 W 120TH AVE STE 312
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-5606
Mailing Address - Country:US
Mailing Address - Phone:720-644-9355
Mailing Address - Fax:720-523-1654
Practice Address - Street 1:5023 W 120TH AVE STE 312
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-5606
Practice Address - Country:US
Practice Address - Phone:720-644-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-24
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0061658207R00000X
FLTRN18507390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL125057956OtherMEDICAL LICENSE-TEMPORARY
FLTRN18507OtherMEDICAL LICENSE - TEMPORARY