Healthcare Provider Details

I. General information

NPI: 1942455746
Provider Name (Legal Business Name): JAYACHANDRA BABU VAVILATHOTA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2008
Last Update Date: 09/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 W DALE ST SUITE 201
WATERLOO IA
50703-1901
US

IV. Provider business mailing address

PO BOX 1455
DES MOINES IA
50306-1455
US

V. Phone/Fax

Practice location:
  • Phone: 319-234-4431
  • Fax: 319-235-5004
Mailing address:
  • Phone: 515-471-9243
  • Fax: 515-471-9319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: