Provider Demographics
NPI:1952481673
Name:MEDAPPA, NERAVANDA K
Entity Type:Individual
Prefix:DR
First Name:NERAVANDA
Middle Name:K
Last Name:MEDAPPA
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:MEDAPPA
Other - Middle Name:
Other - Last Name:NERAVANDA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:65 MEDFORD RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-3217
Mailing Address - Country:US
Mailing Address - Phone:718-273-4367
Mailing Address - Fax:
Practice Address - Street 1:8662 BAY PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-4102
Practice Address - Country:US
Practice Address - Phone:718-714-6489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111428208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00200404Medicaid
NY00200404Medicaid