Provider Demographics
NPI:1588640197
Name:KRISHNAN, RAVI (MD)
Entity Type:Individual
Prefix:
First Name:RAVI
Middle Name:
Last Name:KRISHNAN
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 1:1201 W. LA VETA AVE.
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4203
Mailing Address - Country:US
Mailing Address - Phone:714-509-3096
Mailing Address - Fax:714-509-7800
Practice Address - Street 1:1201 W. LA VETA AVE.
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4203
Practice Address - Country:US
Practice Address - Phone:714-509-3096
Practice Address - Fax:714-509-7800
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC53892208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
G52746Medicare UPIN