Basic Information
| Provider Information | |||||||||
| NPI: | 1336336783 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHERIPALLI | ||||||||
| FirstName: | PRAVEEN | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 RIVERPLACE BLVD | ||||||||
| Address2: | SUITE 620 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322079046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043966620 | ||||||||
| FaxNumber: | 9043966528 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 RIVERPLACE BLVD | ||||||||
| Address2: | SUITE 620 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322079046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043966620 | ||||||||
| FaxNumber: | 9043966528 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2007 | ||||||||
| LastUpdateDate: | 10/29/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 725050925 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | ME104859 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 146J0 | 01 | FL | BC/BS | OTHER | 001941200 | 05 | FL | MEDICAID |