Provider Demographics
NPI:1679552434
Name:RAO, TAKKALLAPELLI D
Entity type:Individual
Prefix:
First Name:TAKKALLAPELLI
Middle Name:D
Last Name:RAO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 AVENUE F NE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4131
Mailing Address - Country:US
Mailing Address - Phone:863-297-1702
Mailing Address - Fax:863-291-6084
Practice Address - Street 1:1201 1ST ST S
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3904
Practice Address - Country:US
Practice Address - Phone:863-297-1702
Practice Address - Fax:863-291-6084
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME886742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279383100Medicaid
FL279383100Medicaid