Basic Information
| Provider Information | |||||||||
| NPI: | 1942455746 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAVILATHOTA | ||||||||
| FirstName: | JAYACHANDRA BABU | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1455 | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503061455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5154719243 | ||||||||
| FaxNumber: | 5154719319 | ||||||||
| Practice Location | |||||||||
| Address1: | 146 W DALE ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507031901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192344431 | ||||||||
| FaxNumber: | 3192355004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2008 | ||||||||
| LastUpdateDate: | 09/28/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 1942455746 | 05 | IA | MEDICAID | P00741043 | 01 | IA | RR MEDICARE | OTHER |