Provider Demographics
NPI:1750466546
Name:RAVILLA, SUDHA
Entity Type:Individual
Prefix:DR
First Name:SUDHA
Middle Name:
Last Name:RAVILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2633 CENTENNIAL BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-0585
Mailing Address - Country:US
Mailing Address - Phone:850-431-5404
Mailing Address - Fax:850-431-4711
Practice Address - Street 1:1981 CAPITAL CIR NE
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4421
Practice Address - Country:US
Practice Address - Phone:850-431-5404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME124689207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine