Provider Demographics
NPI:1982657961
Name:MALLAVARAPU, RAVINDRA (MD)
Entity Type:Individual
Prefix:
First Name:RAVINDRA
Middle Name:
Last Name:MALLAVARAPU
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 2758
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50704-2758
Mailing Address - Country:US
Mailing Address - Phone:319-235-5390
Mailing Address - Fax:319-235-5607
Practice Address - Street 1:1015 S HACKETT RD
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-3500
Practice Address - Country:US
Practice Address - Phone:319-234-5990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA34574207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0266247Medicaid
IA421417307G3OtherJOHN DEERE HEALTH INS PLN
IA47143OtherWELLMARK INS PLAN
IAI6676Medicare ID - Type Unspecified
IA47143OtherWELLMARK INS PLAN