1255577961 NPI number — LAVANYA KORABATHINA MD

Table of content: LAVANYA KORABATHINA MD (NPI 1255577961)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255577961 NPI number — LAVANYA KORABATHINA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KORABATHINA
Provider First Name:
LAVANYA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255577961
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5125 WHITMAN WAY APT 209
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARLSBAD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92008-4632
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
460 N ELM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ESCONDIDO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92025-3002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-737-6960
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208M00000X , with the licence number:  ME110980 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 00243229 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GE691Z . This is a "MEDICARE INDIVIDUAL PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 49067 . This is a "LICENSE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: A119290 . This is a "LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: W14158 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 016099400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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