Healthcare Provider Details

I. General information

NPI: 1518165539
Provider Name (Legal Business Name): KALYANI KORABATHINA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10521 GREENSPRINGS DR
TAMPA FL
33626-1724
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DRIVE MAILBOX 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 760-000-0000
  • Fax:
Mailing address:
  • Phone: 260-266-8210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberA98947
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number01081942A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number15960
License Number StateND
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD28882
License Number StateME
# 5
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME117406
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: