Provider Demographics
NPI:1891952081
Name:CHEETHIRALA, KRISHNAVENI (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISHNAVENI
Middle Name:
Last Name:CHEETHIRALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13900 LAUREL LAKES AVE STE 240
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-5023
Mailing Address - Country:US
Mailing Address - Phone:301-498-1900
Mailing Address - Fax:
Practice Address - Street 1:13900 LAUREL LAKES AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-5091
Practice Address - Country:US
Practice Address - Phone:301-498-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-16
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAGETP.TUL.PED208000000X
MDD72757208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD223316900Medicaid