Provider Demographics
NPI:1104027390
Name:GANGAVALLI, RAVI VENKATA (MD)
Entity Type:Individual
Prefix:DR
First Name:RAVI
Middle Name:VENKATA
Last Name:GANGAVALLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:285 DAVIDSON AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-4153
Mailing Address - Country:US
Mailing Address - Phone:732-271-1400
Mailing Address - Fax:732-271-3544
Practice Address - Street 1:285 DAVIDSON AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-4153
Practice Address - Country:US
Practice Address - Phone:732-271-1400
Practice Address - Fax:732-271-3544
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJMA08271700207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ024248Medicare PIN