MEDICARE: RAVI KONIDALA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QG0300X	Geriatric Medicine (Family Medicine) Physician	M6981	TX
2	207Q00000X	Family Medicine Physician	M6981	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124013552
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAVI KONIDALA MD

Provider Business Mailing Address
First Line	:	511 HEATH ST
Second Line	:
City	:	CROCKETT
State	:	TX
Zip	:	75835-2290
Country	:	US
Telephone Number	:	936-204-0600
Fax Number	:	936-544-8029

Provider Business Practice Location Address
First Line	:	1050 E LOOP 304
Second Line	:	SUITE 200, ETMC RURAL HEALTH CLINIC
City	:	CROCKETT
State	:	TX
Zip	:	75835-1814
Country	:	US
Telephone Number	:	936-544-5132
Fax Number	:	936-544-8029

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2005
Last Update Date	:	06/02/2011

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