Provider Demographics
NPI:1073533881
Name:KORIVI, PRAVEEN (MD)
Entity Type:Individual
Prefix:
First Name:PRAVEEN
Middle Name:
Last Name:KORIVI
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 1:2304 E FLETCHER AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-9404
Mailing Address - Country:US
Mailing Address - Phone:813-615-2273
Mailing Address - Fax:813-632-2000
Practice Address - Street 1:170 S GREEN VALLEY PKWY STE 300
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89012-3145
Practice Address - Country:US
Practice Address - Phone:702-791-1294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93253207Q00000X
NV14422207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004392300Medicaid
I43856Medicare UPIN