Provider Demographics
NPI:1821618281
Name:RAVIKUMAR, VIGNESH
Entity Type:Individual
Prefix:
First Name:VIGNESH
Middle Name:
Last Name:RAVIKUMAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26483 BONITA FAIRWAYS BLVD
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-7542
Mailing Address - Country:US
Mailing Address - Phone:561-336-8069
Mailing Address - Fax:
Practice Address - Street 1:1106 CLEARLAKE RD
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-6402
Practice Address - Country:US
Practice Address - Phone:321-632-3150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-25
Last Update Date:2020-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL59434183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist