Provider Demographics
NPI:1417154451
Name:RAVI, MALLESWARI S (MD)
Entity Type:Individual
Prefix:DR
First Name:MALLESWARI
Middle Name:S
Last Name:RAVI
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:PO BOX 44008
Mailing Address - Street 2:SUITE 304
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-2120
Mailing Address - Fax:904-244-3425
Practice Address - Street 1:653-1 WEST 8TH STREET
Practice Address - Street 2:2ND FLOOR, LRC L14
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209
Practice Address - Country:US
Practice Address - Phone:904-244-3702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2020-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME104972207R00000X, 208M00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0037280-00Medicaid
FL373978308Medicaid
FL0037280-00Medicaid
FL00568Medicare PIN