Provider Demographics
NPI: | 1821030933 |
---|---|
Name: | WALI, RAVINDER K (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | RAVINDER |
Middle Name: | K |
Last Name: | WALI |
Suffix: | |
Gender: | M |
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: | PO BOX 415348 |
Mailing Address - Street 2: | |
Mailing Address - City: | BOSTON |
Mailing Address - State: | MA |
Mailing Address - Zip Code: | 02241-5348 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 800-225-8885 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 55 LAKE AVE N |
Practice Address - Street 2: | |
Practice Address - City: | WORCESTER |
Practice Address - State: | MA |
Practice Address - Zip Code: | 01655-0002 |
Practice Address - Country: | US |
Practice Address - Phone: | 508-334-3155 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-06-12 |
Last Update Date: | 2022-11-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MA | 295408 | 207RN0300X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RN0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MD | 708035-01 | Other | BLUE CROSS/BLUE SHIELD |
VA | 5852170 | Medicaid | |
MD | 0061702400 | Medicaid | |
MD | 708035-01 | Other | BLUE CROSS/BLUE SHIELD |
DE | 0001094301 | Medicaid | |
MD | 0061702400 | Medicaid | |
WV | 2002715000 | Medicaid | |
G92844 | Medicare UPIN |