Basic Information
| Provider Information | |||||||||
| NPI: | 1073749396 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERAVOL | ||||||||
| FirstName: | POOJITHA | ||||||||
| MiddleName: | REDDY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1189 | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973391189 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3615 NW SAMARITAN DR | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973303783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417686930 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2009 | ||||||||
| LastUpdateDate: | 03/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 1343 | WI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | MD60697665 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | MD171595 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.