Provider Demographics
NPI:1114107182
Name:GORANTLA, PRAVEENA (MD)
Entity type:Individual
Prefix:DR
First Name:PRAVEENA
Middle Name:
Last Name:GORANTLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 N WEBB RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3405
Mailing Address - Country:US
Mailing Address - Phone:316-612-4815
Mailing Address - Fax:316-612-4825
Practice Address - Street 1:1921 N WEBB RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3405
Practice Address - Country:US
Practice Address - Phone:316-612-4815
Practice Address - Fax:316-612-4825
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-07
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-33130207RR0500X, 207RR0500X
PAMD437385207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200569320AMedicaid
P01144793OtherRR MEDICARE
P01144793OtherRR MEDICARE