Provider Demographics
NPI:1649288374
Name:VALLABHANENI, RADHA (MD)
Entity type:Individual
Prefix:DR
First Name:RADHA
Middle Name:
Last Name:VALLABHANENI
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:PO BOX 970728
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33097-0728
Mailing Address - Country:US
Mailing Address - Phone:954-796-9666
Mailing Address - Fax:954-796-0333
Practice Address - Street 1:3080 NW 99TH AVE
Practice Address - Street 2:SUITE # 302
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-4038
Practice Address - Country:US
Practice Address - Phone:954-796-9666
Practice Address - Fax:954-796-0333
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME812892084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH37218Medicare UPIN
FL51297Medicare ID - Type Unspecified