Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0129X | Vascular Surgeon | 28968 | MS |
NPI | 1073975298 |
---|---|
Provider Name | Raviteja Naga Devalla |
First Address | Jackson, MS 39216-4500 |
Second Address | Jackson, MS 39216-4500 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/03/2016 |
Last Update Date | 21/07/2021 |