Provider Demographics
NPI:1023012358
Name:KOMANDUR, REVATI (MD)
Entity type:Individual
Prefix:DR
First Name:REVATI
Middle Name:
Last Name:KOMANDUR
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:PSC 10 BOX 1265
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09142-0013
Mailing Address - Country:US
Mailing Address - Phone:314-590-7351
Mailing Address - Fax:
Practice Address - Street 1:LANDSTUHL REGIONAL MEDICAL CENTER
Practice Address - Street 2:UNIT 33100
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180
Practice Address - Country:US
Practice Address - Phone:314-590-7351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9601650207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8910213Medicaid
NC8910213Medicaid
NC2234320DMedicare ID - Type UnspecifiedPROVIDER NUMBER