Provider Demographics
NPI:1942455746
Name:VAVILATHOTA, JAYACHANDRA BABU (MD)
Entity Type:Individual
Prefix:DR
First Name:JAYACHANDRA BABU
Middle Name:
Last Name:VAVILATHOTA
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:PO BOX 1455
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50306-1455
Mailing Address - Country:US
Mailing Address - Phone:515-471-9243
Mailing Address - Fax:515-471-9319
Practice Address - Street 1:146 W DALE ST
Practice Address - Street 2:SUITE 201
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-1901
Practice Address - Country:US
Practice Address - Phone:319-234-4431
Practice Address - Fax:319-235-5004
Is Sole Proprietor?:No
Enumeration Date:2008-11-20
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1942455746Medicaid
IAP00741043OtherRR MEDICARE
IAP00741043OtherRR MEDICARE