Provider Demographics
NPI:1144214065
Name:YADAVA, RAVI (DO)
Entity Type:Individual
Prefix:
First Name:RAVI
Middle Name:
Last Name:YADAVA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 OLD BALLAS RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7083
Mailing Address - Country:US
Mailing Address - Phone:314-994-9355
Mailing Address - Fax:314-994-0796
Practice Address - Street 1:675 OLD BALLAS RD
Practice Address - Street 2:SUITE 210
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7083
Practice Address - Country:US
Practice Address - Phone:314-994-9355
Practice Address - Fax:314-994-0796
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2007-07-08
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-05-01
Provider Licenses
StateLicense IDTaxonomies
MO1040362081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOG48540Medicare UPIN