Provider Demographics
NPI:1194929273
Name:KORIMERLA, PRAVEEN C (MD)
Entity type:Individual
Prefix:
First Name:PRAVEEN
Middle Name:C
Last Name:KORIMERLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PRAVEEN
Other - Middle Name:C
Other - Last Name:KORIMERLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3900 S ZINTEL WAY
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99337-5092
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:509-942-2268
Practice Address - Street 1:1100 GOETHALS DR
Practice Address - Street 2:SUITE E
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3300
Practice Address - Country:US
Practice Address - Phone:509-942-3095
Practice Address - Fax:509-942-3097
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY243005207RC0000X
WAMD60403274207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1538368360Medicaid
WA1538368360Medicaid