Provider Demographics
NPI:1558335273
Name:RAVILOCHAN, KAMASAMUDRAM (MD)
Entity Type:Individual
Prefix:
First Name:KAMASAMUDRAM
Middle Name:
Last Name:RAVILOCHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RAVI
Other - Middle Name:
Other - Last Name:RAVILOCHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 630946
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80163-0946
Mailing Address - Country:US
Mailing Address - Phone:303-589-4757
Mailing Address - Fax:
Practice Address - Street 1:1001 W MINERAL AVE
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80120-4507
Practice Address - Country:US
Practice Address - Phone:303-589-4757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO320482084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01320480Medicaid
COC801076OtherMEDICARE
COF86617Medicare UPIN