Healthcare Provider Details

I. General information

NPI: 1679260509
Provider Name (Legal Business Name): RAVALLIKA PRASUNA KONDA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2023
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 LEXINGTON AVE
ASHLAND KY
41101-2843
US

IV. Provider business mailing address

7601 SOUTHCREST PKWY
SOUTHAVEN MS
38671-4742
US

V. Phone/Fax

Practice location:
  • Phone: 606-408-4000
  • Fax: 606-408-7426
Mailing address:
  • Phone: 662-772-3607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number62054
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number62054
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: