Basic Information
| Provider Information | |||||||||
| NPI: | 1255577961 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KORABATHINA | ||||||||
| FirstName: | LAVANYA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5125 WHITMAN WAY APT 209 | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920084632 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 460 N ELM ST | ||||||||
| Address2: | |||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920253002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607376960 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2008 | ||||||||
| LastUpdateDate: | 10/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | ME110980 | FL | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 00243229 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | GE691Z | 01 | CA | MEDICARE INDIVIDUAL PTAN | OTHER | 49067 | 01 | CT | LICENSE | OTHER | A119290 | 01 | CA | LICENSE | OTHER | W14158 | 01 | CA | MEDICARE GROUP PTAN | OTHER |