Basic Information
| Provider Information | |||||||||
| NPI: | 1942658653 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NETRAVALI | ||||||||
| FirstName: | ILKA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1325 W NORTHWEST HWY | ||||||||
| Address2: | |||||||||
| City: | GRAPEVINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760513141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174213376 | ||||||||
| FaxNumber: | 8174164269 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 W NORTHWEST HWY | ||||||||
| Address2: | |||||||||
| City: | GRAPEVINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760513141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174213376 | ||||||||
| FaxNumber: | 8174164269 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2016 | ||||||||
| LastUpdateDate: | 09/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207NP0225X | T8898 | TX | N | Allopathic & Osteopathic Physicians | Dermatology | Pediatric Dermatology | 207N00000X | T8898 | TX | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.