Provider Demographics
NPI:1326354465
Name:BOORGULA, RAVINDER (MD)
Entity Type:Individual
Prefix:DR
First Name:RAVINDER
Middle Name:
Last Name:BOORGULA
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 1:67 MAPLE AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1328
Mailing Address - Country:US
Mailing Address - Phone:203-732-1330
Mailing Address - Fax:203-732-1332
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2689
Practice Address - Country:US
Practice Address - Phone:800-653-6568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-26
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT61524208M00000X, 207R00000X
PAMD448993207R00000X, 208M00000X
LA320013207R00000X
MI4301502340207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008081636Medicaid