Provider Demographics
NPI:1558511865
Name:NERAVETLA, SOUMYA (MD)
Entity Type:Individual
Prefix:
First Name:SOUMYA
Middle Name:
Last Name:NERAVETLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1671 N LIMESTONE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-2646
Mailing Address - Country:US
Mailing Address - Phone:937-324-5511
Mailing Address - Fax:937-398-0652
Practice Address - Street 1:1671 N LIMESTONE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-2646
Practice Address - Country:US
Practice Address - Phone:937-324-5511
Practice Address - Fax:937-398-0652
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA066970208600000X, 208G00000X
OH35.129702208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0189204Medicaid
12455059OtherCAQH