Provider Demographics
NPI:1205949120
Name:VEMURU, RAVIKUMAR (MD)
Entity type:Individual
Prefix:
First Name:RAVIKUMAR
Middle Name:
Last Name:VEMURU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-5133
Mailing Address - Country:US
Mailing Address - Phone:432-333-3433
Mailing Address - Fax:432-333-3450
Practice Address - Street 1:315 E 5TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5133
Practice Address - Country:US
Practice Address - Phone:432-333-3433
Practice Address - Fax:432-333-3450
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5044174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMU8947OtherMEDICAID
TX080701802Medicaid
TX100012089OtherRAILROAD MEDICARE
TX126089100OtherFIRSTCARE
TX87130KMedicare PIN