Provider Demographics
NPI:1346502697
Name:KOORAGAYALU, SHRAVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SHRAVAN
Middle Name:
Last Name:KOORAGAYALU
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:PO BOX 1671
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21501-1671
Mailing Address - Country:US
Mailing Address - Phone:240-964-8342
Mailing Address - Fax:240-964-8337
Practice Address - Street 1:12502 WILLOWBROOK RD STE 280
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-6494
Practice Address - Country:US
Practice Address - Phone:240-964-8750
Practice Address - Fax:240-964-8699
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-12
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00292848207RP1001X
390200000X
MDD90372207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty