Provider Demographics
NPI:1275658528
Name:RADHA VALLABHANENI MD LLC
Entity Type:Organization
Organization Name:RADHA VALLABHANENI MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RADHA
Authorized Official - Middle Name:
Authorized Official - Last Name:VALLABHANENI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-796-9666
Mailing Address - Street 1:PO BOX 970728
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33097-0728
Mailing Address - Country:US
Mailing Address - Phone:954-796-9666
Mailing Address - Fax:954-796-0333
Practice Address - Street 1:3080 NW 99TH AVE
Practice Address - Street 2:SUITE # 302
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-4038
Practice Address - Country:US
Practice Address - Phone:954-796-9666
Practice Address - Fax:954-796-0333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME812892084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009430500Medicaid
FL251368400Medicaid