Provider Demographics
NPI:1669856217
Name:BANAJJAR REVANASIDDAPPA, VANITHA (MD)
Entity type:Individual
Prefix:DR
First Name:VANITHA
Middle Name:
Last Name:BANAJJAR REVANASIDDAPPA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:VANITHA
Other - Middle Name:
Other - Last Name:BANAJJAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1718 E 4TH ST STE 907
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3282
Practice Address - Country:US
Practice Address - Phone:704-372-4000
Practice Address - Fax:704-334-4855
Is Sole Proprietor?:No
Enumeration Date:2015-07-14
Last Update Date:2025-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2025-01298207V00000X
390200000X
CAA162179207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1669856217Medicaid