Provider Demographics
NPI:1437463593
Name:GANGULA, SHRAVAN KUMAR REDDY (MD)
Entity Type:Individual
Prefix:
First Name:SHRAVAN
Middle Name:KUMAR REDDY
Last Name:GANGULA
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 1:8337 E 81ST ST APT 1237
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-8088
Mailing Address - Country:US
Mailing Address - Phone:615-415-5392
Mailing Address - Fax:
Practice Address - Street 1:1400 W 4TH ST
Practice Address - Street 2:
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-3306
Practice Address - Country:US
Practice Address - Phone:620-688-6566
Practice Address - Fax:620-688-6577
Is Sole Proprietor?:No
Enumeration Date:2010-07-31
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27717207Q00000X
KS0436385207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine