Provider Demographics
NPI:1144230905
Name:RAVITSKIY, LARISA (MD)
Entity Type:Individual
Prefix:DR
First Name:LARISA
Middle Name:
Last Name:RAVITSKIY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 MORRISON RD
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-5342
Mailing Address - Country:US
Mailing Address - Phone:614-585-9900
Mailing Address - Fax:614-585-9999
Practice Address - Street 1:602 MORRISON RD
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230
Practice Address - Country:US
Practice Address - Phone:614-585-9900
Practice Address - Fax:614-585-9999
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35092083207ND0101X, 207N00000X
AZ41743207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2901560Medicaid
OH4241981Medicare PIN