Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2086S0120X | Pediatric Surgery | 036103187 | IL |
Y | 2086S0120X | Pediatric Surgery | 42746 | AZ |
NPI | 1346280203 |
---|---|
Provider Name | Dr. Ravindra Kumar Vegunta |
First Address | Mesa, AZ 85202-4768 |
Second Address | Mesa, AZ 85202-4768 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/06/2006 |
Last Update Date | 09/11/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036103187 | (05) | IL |
809840 | GROUP (01) | IL |
G97857 | (02) | IL |
K33862 | INDIVIDUAL (01) | IL |