Provider Demographics
NPI:1043382385
Name:SURAKANTI, RAVINDER (MD)
Entity Type:Individual
Prefix:
First Name:RAVINDER
Middle Name:
Last Name:SURAKANTI
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 1:1710 LAFAYETTE RD
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-1033
Mailing Address - Country:US
Mailing Address - Phone:765-361-3012
Mailing Address - Fax:
Practice Address - Street 1:1704 LAFAYETTE RD
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-1071
Practice Address - Country:US
Practice Address - Phone:765-364-1252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034655A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000093742OtherANTHEM ID #
IN100185610AMedicaid
IN000000093742OtherANTHEM ID #
IN150970BMedicare PIN
INB29206Medicare UPIN