Provider Demographics
NPI:1730133547
Name:CHANDRAN, RAVI THEETHAKARAI (MD)
Entity Type:Individual
Prefix:
First Name:RAVI
Middle Name:THEETHAKARAI
Last Name:CHANDRAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:864-482-4000
Practice Address - Street 1:125 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-2558
Practice Address - Country:US
Practice Address - Phone:864-482-3000
Practice Address - Fax:864-482-4000
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23128207RP1001X, 261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC231289Medicaid