Provider Demographics
NPI:1023221413
Name:EDALUR, RAVIKUMAR HANUMANTHAIAH (MD)
Entity Type:Individual
Prefix:DR
First Name:RAVIKUMAR
Middle Name:HANUMANTHAIAH
Last Name:EDALUR
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 1:1005 N EASTMAN RD
Mailing Address - Street 2:NONE
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-4231
Mailing Address - Country:US
Mailing Address - Phone:903-239-1518
Mailing Address - Fax:903-247-8273
Practice Address - Street 1:1005 N EASTMAN RD
Practice Address - Street 2:NONE
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-4231
Practice Address - Country:US
Practice Address - Phone:903-239-1518
Practice Address - Fax:903-247-8273
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063441A207Q00000X
TXM7245207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1492033201Medicaid