Provider Demographics
NPI:1548299662
Name:JANNAIAH C. TRIPURANENI MD LLC
Entity type:Organization
Organization Name:JANNAIAH C. TRIPURANENI MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANNAIAH
Authorized Official - Middle Name:C
Authorized Official - Last Name:TRIPURANENI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:225-667-5454
Mailing Address - Street 1:230 VETERANS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-4700
Mailing Address - Country:US
Mailing Address - Phone:225-667-5454
Mailing Address - Fax:225-667-5451
Practice Address - Street 1:230 VETERANS BLVD STE A
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-4700
Practice Address - Country:US
Practice Address - Phone:225-667-5454
Practice Address - Fax:225-667-5451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAR11566207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1679453Medicaid
LA1679453Medicaid