Provider Demographics
NPI:1912924911
Name:GADIRAJU, RAVI KUMAR RAJU
Entity Type:Individual
Prefix:
First Name:RAVI
Middle Name:KUMAR RAJU
Last Name:GADIRAJU
Suffix:
Gender:M
Credentials:
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-5416
Mailing Address - Fax:704-384-5992
Practice Address - Street 1:200 HAWTHORNE LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2515
Practice Address - Country:US
Practice Address - Phone:704-384-5416
Practice Address - Fax:704-384-5992
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-01018208M00000X, 207R00000X
IN01062363A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200840670Medicaid
NC5907666Medicaid
SCN0101DMedicaid
SCN0101DMedicaid
SCN0101DMedicaid
NC2071586Medicare PIN
IN200840670Medicaid
NC5907666Medicaid
IN221780CMedicare PIN