Provider Demographics
NPI:1043293210
Name:VIRALAM, PRABHAVATHI KATTA (MD)
Entity Type:Individual
Prefix:
First Name:PRABHAVATHI
Middle Name:KATTA
Last Name:VIRALAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3365 BURNS RD
Mailing Address - Street 2:STE 217
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4326
Mailing Address - Country:US
Mailing Address - Phone:561-627-7433
Mailing Address - Fax:561-775-1055
Practice Address - Street 1:3365 BURNS RD
Practice Address - Street 2:STE 217
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-4326
Practice Address - Country:US
Practice Address - Phone:561-627-7433
Practice Address - Fax:561-775-1055
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME006302207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL378758300Medicaid
G02079Medicare UPIN
FL26547Medicare ID - Type Unspecified