Provider Demographics
NPI:1194820043
Name:MOOTHA, RAVI K (MD)
Entity Type:Individual
Prefix:
First Name:RAVI
Middle Name:K
Last Name:MOOTHA
Suffix:
Gender:M
Credentials:MD
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2821 E PRESIDENT GEORGE BUSH HWY
Mailing Address - Street 2:SUITE 305
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-4266
Mailing Address - Country:US
Mailing Address - Phone:972-235-3248
Mailing Address - Fax:972-235-3984
Practice Address - Street 1:2821 E PRESIDENT GEORGE BUSH HWY
Practice Address - Street 2:SUITE 305
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-4266
Practice Address - Country:US
Practice Address - Phone:972-235-3248
Practice Address - Fax:972-235-3984
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2009-09-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL7054208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology