Provider Demographics
NPI:1487876439
Name:THANGEDA, SRAVAN K (MD)
Entity type:Individual
Prefix:
First Name:SRAVAN
Middle Name:K
Last Name:THANGEDA
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 1:38135 MARKET SQ
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7505
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10991 SAN JOSE BLVD # 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-6675
Practice Address - Country:US
Practice Address - Phone:904-839-1263
Practice Address - Fax:904-656-7306
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME122293208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01349723OtherMEDICARE RAILROAD (INDIVIDUAL)
IL920540OtherMEDICARE PTAN (GROUP)
IL036116994OtherMEDICARE
IL920540040OtherMEDICARE PTAN (INDIVIDUAL)
ILCA4748OtherMEDICARE RAILROAD (GROUP)