Basic Information
Provider Information | |||||||||
NPI: | 1457509168 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | IYENGAR | ||||||||
FirstName: | REVATHI | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SATHYAN | ||||||||
OtherFirstName: | REVATHI | ||||||||
OtherMiddleName: | R | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 100236 | ||||||||
Address2: |   | ||||||||
City: | GAINESVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 326100236 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3522735550 | ||||||||
FaxNumber: | 3522735575 | ||||||||
Practice Location | |||||||||
Address1: | 600 E DIXIE AVE | ||||||||
Address2: |   | ||||||||
City: | LEESBURG | ||||||||
State: | FL | ||||||||
PostalCode: | 347485925 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3523235467 | ||||||||
FaxNumber: | 3523153633 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/05/2008 | ||||||||
LastUpdateDate: | 02/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/10/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0600X | ME113806 | FL | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084N0400X | ME113806 | FL | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.