Provider Demographics
NPI:1700824224
Name:RAVOORI, SUDHA R (MD)
Entity Type:Individual
Prefix:DR
First Name:SUDHA
Middle Name:R
Last Name:RAVOORI
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 1:110 EDGEWATER TRL
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-1811
Mailing Address - Country:US
Mailing Address - Phone:770-479-1417
Mailing Address - Fax:208-275-1349
Practice Address - Street 1:110 EDGEWATER TRL
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-1811
Practice Address - Country:US
Practice Address - Phone:770-479-1417
Practice Address - Fax:208-275-1349
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00025176207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK51002923OtherBLUE CROSS HOSPITAL BASED
AL51532371OtherBLUE CROSS PHYSICIAN BASE
GA05BDLMSMedicare PIN
AL51532371OtherBLUE CROSS PHYSICIAN BASE
AK51002923OtherBLUE CROSS HOSPITAL BASED