Provider Demographics
NPI:1679643191
Name:KANNEGANTI, RAVIKUMAR (MD)
Entity Type:Individual
Prefix:
First Name:RAVIKUMAR
Middle Name:
Last Name:KANNEGANTI
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 21313
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77720-1313
Mailing Address - Country:US
Mailing Address - Phone:409-813-1765
Mailing Address - Fax:409-813-1875
Practice Address - Street 1:3250 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-4627
Practice Address - Country:US
Practice Address - Phone:409-813-1765
Practice Address - Fax:409-813-1875
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH68672084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114668001Medicaid
TX114668001Medicaid
00G71BMedicare PIN