Provider Demographics
NPI:1790931715
Name:SHASTRI, RAVI K (MD)
Entity Type:Individual
Prefix:
First Name:RAVI
Middle Name:K
Last Name:SHASTRI
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 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:616-252-3243
Mailing Address - Fax:616-252-0260
Practice Address - Street 1:2122 HEALTH DR SW STE 160
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9402
Practice Address - Country:US
Practice Address - Phone:616-252-5790
Practice Address - Fax:616-252-5793
Is Sole Proprietor?:No
Enumeration Date:2008-08-10
Last Update Date:2018-03-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI43011030782085N0700X, 2085R0202X
AZR70528208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No208600000XAllopathic & Osteopathic PhysiciansSurgery