Healthcare Provider Details

I. General information

NPI: 1689677809
Provider Name (Legal Business Name): IDYA PRAVEEN KUMAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13301 MILES AVE
CLEVELAND OH
44105-5521
US

IV. Provider business mailing address

4800 PAYNE AVE
CLEVELAND OH
44103-2443
US

V. Phone/Fax

Practice location:
  • Phone: 216-751-3100
  • Fax: 216-751-2480
Mailing address:
  • Phone: 216-231-7700
  • Fax: 216-231-3828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35066270
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: