Provider Demographics
NPI:1144221904
Name:KHANNA, RAVI C (MD)
Entity Type:Individual
Prefix:
First Name:RAVI
Middle Name:C
Last Name:KHANNA
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 1:148 W NORTH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-2547
Mailing Address - Country:US
Mailing Address - Phone:937-323-5001
Mailing Address - Fax:937-323-5413
Practice Address - Street 1:148 W NORTH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-2547
Practice Address - Country:US
Practice Address - Phone:937-323-5001
Practice Address - Fax:937-323-5413
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35040509K207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0399153Medicaid
OHA75810Medicare UPIN
OH0399153Medicaid