Provider Demographics
NPI:1124013552
Name:KONIDALA, RAVI (MD)
Entity Type:Individual
Prefix:
First Name:RAVI
Middle Name:
Last Name:KONIDALA
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 1:511 HEATH ST
Mailing Address - Street 2:
Mailing Address - City:CROCKETT
Mailing Address - State:TX
Mailing Address - Zip Code:75835-2290
Mailing Address - Country:US
Mailing Address - Phone:936-204-0600
Mailing Address - Fax:936-544-8029
Practice Address - Street 1:1050 E LOOP 304
Practice Address - Street 2:SUITE 200, ETMC RURAL HEALTH CLINIC
Practice Address - City:CROCKETT
Practice Address - State:TX
Practice Address - Zip Code:75835-1814
Practice Address - Country:US
Practice Address - Phone:936-544-5132
Practice Address - Fax:936-544-8029
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM6981207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1010424560001Medicaid
PAI09028Medicare UPIN
PA1010424560001Medicaid