Provider Demographics
NPI:1255775987
Name:MEDAVARAM, SOWMINI (MD)
Entity type:Individual
Prefix:DR
First Name:SOWMINI
Middle Name:
Last Name:MEDAVARAM
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 1:2500 FOUNDATION WAY
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-9000
Mailing Address - Country:US
Mailing Address - Phone:304-264-9202
Mailing Address - Fax:304-294-9042
Practice Address - Street 1:2000 FOUNDATION WAY STE 2600
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-9197
Practice Address - Country:US
Practice Address - Phone:304-267-1944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-24
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WV29028207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program