Provider Demographics
NPI:1265521058
Name:KODURU, RAVI K (MD)
Entity type:Individual
Prefix:DR
First Name:RAVI
Middle Name:K
Last Name:KODURU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 E TRAILWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-9606
Mailing Address - Country:US
Mailing Address - Phone:812-478-8888
Mailing Address - Fax:812-478-1114
Practice Address - Street 1:1332 N 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-1004
Practice Address - Country:US
Practice Address - Phone:812-478-8888
Practice Address - Fax:812-478-1114
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057643A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00057068OtherRR MEDICARE
INP01045883OtherRAILROAD MEDICARE
IN000000299607OtherCOMMERCIAL
IN200456210Medicaid
INP00057068OtherRR MEDICARE
215950CMedicare ID - Type Unspecified
IN200456210Medicaid
INP01045883OtherRAILROAD MEDICARE