Provider Demographics
NPI:1255577961
Name:KORABATHINA, LAVANYA (MD)
Entity type:Individual
Prefix:
First Name:LAVANYA
Middle Name:
Last Name:KORABATHINA
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 1:5125 WHITMAN WAY APT 209
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-4632
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:460 N ELM ST
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-3002
Practice Address - Country:US
Practice Address - Phone:760-737-6960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-30
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME110980208M00000X
NY00243229207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGE691ZOtherMEDICARE INDIVIDUAL PTAN
CT49067OtherLICENSE
CAA119290OtherLICENSE
CAW14158OtherMEDICARE GROUP PTAN