Provider Demographics
NPI:1730178377
Name:VENKAT, KALYAN R (MD)
Entity type:Individual
Prefix:DR
First Name:KALYAN
Middle Name:R
Last Name:VENKAT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:KALYAN
Other - Middle Name:ASUNDARAM
Other - Last Name:VENKATARAMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:40 HURLEY AVE
Mailing Address - Street 2:SUITE 17
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-3739
Mailing Address - Country:US
Mailing Address - Phone:845-338-3212
Mailing Address - Fax:845-339-0299
Practice Address - Street 1:40 HURLEY AVE
Practice Address - Street 2:SUITE 17
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-3739
Practice Address - Country:US
Practice Address - Phone:845-338-3212
Practice Address - Fax:845-339-0299
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY136378-1208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00573331Medicaid
NYE45990Medicare UPIN
NY00573331Medicaid