Basic Information
| Provider Information | |||||||||
| NPI: | 1821088709 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | TRIPURANENI | ||||||||
| FirstName: | JANNAIAH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2647 S SAINT ELIZABETH BLVD | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707375021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256478511 | ||||||||
| FaxNumber: | 2256445213 | ||||||||
| Practice Location | |||||||||
| Address1: | 2647 S SAINT ELIZABETH BLVD | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707375021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256478511 | ||||||||
| FaxNumber: | 2256445213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 06/06/2016 | ||||||||
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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 | 11566R | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207P00000X | MD.1566R | LA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 208M00000X | 11566R | LA | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 1679453 | 05 | LA | MEDICAID |