Provider Demographics
NPI:1336336783
Name:CHERIPALLI, PRAVEEN (MD)
Entity type:Individual
Prefix:
First Name:PRAVEEN
Middle Name:
Last Name:CHERIPALLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 RIVERPLACE BLVD
Mailing Address - Street 2:SUITE 620
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-9046
Mailing Address - Country:US
Mailing Address - Phone:904-396-6620
Mailing Address - Fax:904-396-6528
Practice Address - Street 1:1200 RIVERPLACE BLVD
Practice Address - Street 2:SUITE 620
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-9046
Practice Address - Country:US
Practice Address - Phone:904-396-6620
Practice Address - Fax:904-396-6528
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL725050925207R00000X
FLME104859207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL146J0OtherBC/BS
FL001941200Medicaid
FLCI537ZMedicare PIN