Provider Demographics
NPI:1932316098
Name:VALIVETI, PRAKASH (MD)
Entity Type:Individual
Prefix:
First Name:PRAKASH
Middle Name:
Last Name:VALIVETI
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 1:4516 N ARMENIA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-2732
Mailing Address - Country:US
Mailing Address - Phone:813-348-6915
Mailing Address - Fax:813-348-6999
Practice Address - Street 1:3001 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6307
Practice Address - Country:US
Practice Address - Phone:813-348-6915
Practice Address - Fax:813-348-6999
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-018712085R0202X
NV134362085R0202X
VA0116017014390200000X
FLME1316142085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200472840AMedicaid
NVP01168796OtherRR MEDICARE
NVNPI 1932316098Medicaid
OK200472840AMedicaid
NVDJ793ZMedicare PIN