Provider Demographics
NPI:1366419210
Name:VARANASI, BALAVITTAL (MD)
Entity type:Individual
Prefix:DR
First Name:BALAVITTAL
Middle Name:
Last Name:VARANASI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:B.VITTAL
Other - Middle Name:
Other - Last Name:VARANASI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:936 M L KING DR
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3058
Mailing Address - Country:US
Mailing Address - Phone:618-532-6439
Mailing Address - Fax:618-532-1549
Practice Address - Street 1:936 M L KING DR
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3058
Practice Address - Country:US
Practice Address - Phone:618-532-6439
Practice Address - Fax:618-532-1549
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-085451207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA14871Medicare UPIN