Provider Demographics
NPI:1689651770
Name:EDUPUGANTI, RAVINDRA (MD)
Entity Type:Individual
Prefix:
First Name:RAVINDRA
Middle Name:
Last Name:EDUPUGANTI
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 1:55 WHITCHER ST NE STE 350
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1129
Mailing Address - Country:US
Mailing Address - Phone:770-424-6893
Mailing Address - Fax:770-424-9095
Practice Address - Street 1:55 WHITCHER ST NE
Practice Address - Street 2:SUITE 350
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1155
Practice Address - Country:US
Practice Address - Phone:770-424-6893
Practice Address - Fax:678-819-0357
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA063858207UN0901X, 208600000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003110591JMedicaid
GA003110591LMedicaid
GA003110591MMedicaid
GA003110591HMedicaid
GA003110591CMedicaid
GA003110591IMedicaid
GA003110591FMedicaid
GA003110591KMedicaid
GA003110591DMedicaid
GA003110591EMedicaid
GA003110591GMedicaid
GA003110591MMedicaid