Provider Demographics
NPI:1881671204
Name:RAVISANKAR, JAYANTHI (MD)
Entity Type:Individual
Prefix:
First Name:JAYANTHI
Middle Name:
Last Name:RAVISANKAR
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 1:1010 MAIN ST S
Mailing Address - Street 2:
Mailing Address - City:MC KEE
Mailing Address - State:KY
Mailing Address - Zip Code:40447-7089
Mailing Address - Country:US
Mailing Address - Phone:606-287-7104
Mailing Address - Fax:606-287-4409
Practice Address - Street 1:104 LEGACY DR
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-9594
Practice Address - Country:US
Practice Address - Phone:859-986-2323
Practice Address - Fax:859-986-7728
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34558208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64354582Medicaid
KY0068118Medicare PIN
KY64354582Medicaid