Provider Demographics
NPI:1063454692
Name:NANDAKUMAR RAVI MD A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:NANDAKUMAR RAVI MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:AMERICAN DIGESTIVE LIVER AND NUTRITIONAL DISEASE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NANDAKUMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:RAVI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-588-8725
Mailing Address - Street 1:PO BOX 22470
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93390-2470
Mailing Address - Country:US
Mailing Address - Phone:661-588-8725
Mailing Address - Fax:661-588-8749
Practice Address - Street 1:9870 BRIMHALL RD UNIT 100
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93312-2798
Practice Address - Country:US
Practice Address - Phone:661-588-8725
Practice Address - Fax:661-588-8749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64007207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A640070Medicaid
CA00A640070Medicaid