Provider Demographics
NPI:1578632667
Name:DEVABHAKTHUNI, BABU R (MD)
Entity Type:Individual
Prefix:DR
First Name:BABU
Middle Name:R
Last Name:DEVABHAKTHUNI
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 1:312 10TH ST
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-3611
Mailing Address - Country:US
Mailing Address - Phone:304-366-2818
Mailing Address - Fax:304-366-7614
Practice Address - Street 1:312 10TH ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-3611
Practice Address - Country:US
Practice Address - Phone:304-366-2818
Practice Address - Fax:304-366-7614
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11553208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0108284000Medicaid
WV0108284000Medicaid