Basic Information
| Provider Information | |||||||||
| NPI: | 1689651770 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDUPUGANTI | ||||||||
| FirstName: | RAVINDRA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WHITCHER ST NE STE 350 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704246893 | ||||||||
| FaxNumber: | 7704249095 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 WHITCHER ST NE | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704246893 | ||||||||
| FaxNumber: | 6788190357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 12/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/18/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207UN0901X | 063858 | GA | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 208600000X | 063858 | GA | N | Allopathic & Osteopathic Physicians | Surgery | 207RC0000X | 063858 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 003110591J | 05 | GA | MEDICAID | 003110591L | 05 | GA | MEDICAID | 003110591M | 05 | GA | MEDICAID | 003110591H | 05 | GA | MEDICAID | 003110591C | 05 | GA | MEDICAID | 003110591I | 05 | GA | MEDICAID | 003110591F | 05 | GA | MEDICAID | 003110591K | 05 | GA | MEDICAID | 003110591D | 05 | GA | MEDICAID | 003110591E | 05 | GA | MEDICAID | 003110591G | 05 | GA | MEDICAID |