Provider Demographics
NPI:1760452965
Name:GHATNEKAR, REVATI J (MD)
Entity Type:Individual
Prefix:
First Name:REVATI
Middle Name:J
Last Name:GHATNEKAR
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 1:25 SHERWOOD RD
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1648
Mailing Address - Country:US
Mailing Address - Phone:760-625-5876
Mailing Address - Fax:760-699-5521
Practice Address - Street 1:1180 N INDIAN CANYON DR STE E205
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4876
Practice Address - Country:US
Practice Address - Phone:760-325-1202
Practice Address - Fax:760-864-7105
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052299207RC0000X, 207UN0901X
CAC43133207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
060062081OtherRAILROAD
IN000000183123OtherANTHEM
060062081OtherRAILROAD
IN200313830Medicaid
IN260690CCOtherMEDICARE
OH0838231Medicaid
IN000000183123OtherANTHEM
060062081OtherRAILROAD
IN200313830Medicaid