Provider Demographics
NPI:1851353718
Name:TARAVATH, SASIDHARAN (MD)
Entity Type:Individual
Prefix:
First Name:SASIDHARAN
Middle Name:
Last Name:TARAVATH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 986513
Mailing Address - Street 2:DEPT 100
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02298-6513
Mailing Address - Country:US
Mailing Address - Phone:910-219-8326
Mailing Address - Fax:910-939-4269
Practice Address - Street 1:156 MEMORIAL CT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6322
Practice Address - Country:US
Practice Address - Phone:910-785-8145
Practice Address - Fax:910-353-3629
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9999992080P0008X
NC2014-001962084N0400X, 2084S0012X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0090530000Medicaid
WV0090530000Medicaid