Provider Demographics
NPI:1962587295
Name:KODALI, RAVI PRAKASH (MD)
Entity type:Individual
Prefix:
First Name:RAVI
Middle Name:PRAKASH
Last Name:KODALI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 CHERRY ST
Mailing Address - Street 2:ATTN: MRG ASSOCIATES, LLC - RADIOLOGY DEPT.
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43608-2603
Mailing Address - Country:US
Mailing Address - Phone:419-251-4340
Mailing Address - Fax:
Practice Address - Street 1:2213 CHERRY ST
Practice Address - Street 2:ATTN: MRG ASSOCIATES, LLC - RADIOLOGY DEPT.
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43608-2603
Practice Address - Country:US
Practice Address - Phone:419-251-4340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350836232085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2504758Medicaid
OH35083623OtherOH MEDICAL LICENSE
OH35083623OtherOH MEDICAL LICENSE
OHBK4759049OtherDEA NUMBER
G46848Medicare UPIN
OHH085881Medicare PIN