Doctor Name: | DR. RAVINDHRA CHAKRAVARTHI MAMILLA |
NPI Number: | 1679883300 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | MD |
License Number: | |
Business Practice Address: | 1720 Highway 59 S Thief River Falls, MN - 567014331 |
Business Phone Number: | 2186832676 |
Business Fax Number: | |
Mailing Address: | 1720 Highway 59 S, THIEF RIVER FALLS |
State: | MN |
Postal Code: | 567014331 |
Phone Number: | 2186832676 |
Fax Number: | |
NPI Enumeration Date: | 10/15/2010 |
NPI Last Update Date: | 12/20/2012 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 390200000X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | N |
State: | |
Taxonomy Type: | Student, Health Care |
Taxonomy Classification: | Student in an Organized Health Care Education/Training Program |
Taxonomy Specialization: | |
Taxonomy Definition: | An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care. |