Provider Demographics
NPI:1417226721
Name:KETHINENI, RAMA K (MBBS)
Entity type:Individual
Prefix:
First Name:RAMA
Middle Name:K
Last Name:KETHINENI
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N 1900 E RM 4R312
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-0002
Mailing Address - Country:US
Mailing Address - Phone:801-581-6709
Mailing Address - Fax:
Practice Address - Street 1:557 SANDHURST DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4433
Practice Address - Country:US
Practice Address - Phone:910-484-8114
Practice Address - Fax:910-223-0511
Is Sole Proprietor?:No
Enumeration Date:2011-12-16
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11729248-1205207RN0300X
NC2023-02989207RN0300X
OH35.125862207R00000X
IN01070789A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201078420Medicaid
IN000000766020OtherANTHEM
IN201078420Medicaid