Provider Demographics
NPI:1285945758
Name:MUMMANENI, REVATI (MD)
Entity type:Individual
Prefix:DR
First Name:REVATI
Middle Name:
Last Name:MUMMANENI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:REVATI
Other - Middle Name:
Other - Last Name:MUMMANENI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4400 N SCOTTSDALE RD
Mailing Address - Street 2:STE 9841
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-3331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4400 N SCOTTSDALE RD
Practice Address - Street 2:STE 9841
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-3331
Practice Address - Country:US
Practice Address - Phone:248-390-4503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR71974207R00000X
VA390200000X
AZ50905208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZR71974OtherTRAINING PERMIT