Provider Demographics
NPI:1679780373
Name:AVATI NANJUNDAPPA, RAVI PRASAD (MD, MPH)
Entity type:Individual
Prefix:
First Name:RAVI PRASAD
Middle Name:
Last Name:AVATI NANJUNDAPPA
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-296-5691
Mailing Address - Fax:904-450-6401
Practice Address - Street 1:1658 ST VINCENTS WAY STE 300
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068
Practice Address - Country:US
Practice Address - Phone:904-276-5100
Practice Address - Fax:904-276-5393
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA61823207R00000X
LAMD.206105207RC0000X
FLME135622207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2339648Medicaid
MS06936506Medicaid
LA297357YH3UMedicare PIN