Provider Demographics
NPI:1083609226
Name:RAVINDRA, NAGELLA (MD)
Entity Type:Individual
Prefix:DR
First Name:NAGELLA
Middle Name:
Last Name:RAVINDRA
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 1:4801 49TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-3859
Mailing Address - Country:US
Mailing Address - Phone:727-526-3468
Mailing Address - Fax:727-526-3468
Practice Address - Street 1:4801 49TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-3859
Practice Address - Country:US
Practice Address - Phone:727-526-3468
Practice Address - Fax:727-526-3468
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0036317174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065105200Medicaid
FLD57374Medicare UPIN
FL62261Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL NUMBE