Provider Demographics
NPI:1013026830
Name:JERATH, RAVINDER (MD)
Entity Type:Individual
Prefix:MR
First Name:RAVINDER
Middle Name:
Last Name:JERATH
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 1:2100 CENTRAL AVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-6717
Mailing Address - Country:US
Mailing Address - Phone:706-736-5378
Mailing Address - Fax:706-738-9922
Practice Address - Street 1:2100 CENTRAL AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-6717
Practice Address - Country:US
Practice Address - Phone:706-736-5378
Practice Address - Fax:706-738-9922
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA19957207VG0400X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10048449OtherAMERIGROUP
GA342733OtherWELLCARE MEDICAID
GA00233901AMedicaid
SCG19957Medicaid
GA19957OtherSTATE LICENSE
GABJ0393114OtherDEA NUMBER
GA342733OtherWELLCARE MEDICAID