Provider Demographics
NPI:1235125634
Name:RAVESSOUD, FERNANDO (MD)
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
Last Name:RAVESSOUD
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 1:880 S TELSHOR BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8601
Mailing Address - Country:US
Mailing Address - Phone:575-222-0037
Mailing Address - Fax:575-571-4592
Practice Address - Street 1:880 S TELSHOR BLVD STE 201
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8682
Practice Address - Country:US
Practice Address - Phone:575-222-0037
Practice Address - Fax:575-571-4592
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2022-11-18
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-12
Provider Licenses
StateLicense IDTaxonomies
NMMD2011-0758207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM95425578Medicaid
NMP01102858OtherRR MEDICARE
NMNMAAA2050Medicare PIN
NMA46175Medicare UPIN