Provider Demographics
NPI:1023060266
Name:KONERU, REVATHI NAGABHAIRU (MD)
Entity type:Individual
Prefix:DR
First Name:REVATHI
Middle Name:NAGABHAIRU
Last Name:KONERU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:REVATHI
Other - Middle Name:
Other - Last Name:NAGABHAIRU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1826 VETERANS BLVD
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-3620
Mailing Address - Country:US
Mailing Address - Phone:478-272-1210
Mailing Address - Fax:
Practice Address - Street 1:1826 VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-3620
Practice Address - Country:US
Practice Address - Phone:478-272-1210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2249492084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry