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Ravi Konidala

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NPI Number Detailed Information

Provider Information:

Name: Ravi Konidala
Gender: M
Provider License Number If Given: M6981

NPI Information:

NPI: 1124013552
Entity Type
(Individual or Organization):
1-ind
Enumeration Date: 9/12/2005

Last Update Date: 6/2/2011

Provider Business Mailing Address:

Address: 511 HEATH ST
Crockett, TX 75835
Phone Number: 9362040600
Fax Number: 9365448029

Provider Business Practice Location Address:

Address: 1050 E LOOP 304 SUITE 200, ETMC RURAL HEALTH CLINIC
Crockett, TX 75835
Phone Number: 9365445132
Fax Number: 9365448029

Provider Taxonomy:

Primary: 207Q00000X
Secondary (if any): 207QG0300X
State: TX

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