Provider Demographics
NPI:1801843602
Name:NERAVETLA, SURENDER R (MD)
Entity Type:Individual
Prefix:
First Name:SURENDER
Middle Name:R
Last Name:NERAVETLA
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 1:1671 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:2006-05-27
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0459462086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0512181Medicaid
OH0512181Medicaid