Provider Demographics
NPI:1922047869
Name:GANGADHARIAH, RAVINDRAKUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:RAVINDRAKUMAR
Middle Name:
Last Name:GANGADHARIAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RAVI
Other - Middle Name:
Other - Last Name:KUMAR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4624 PROGRESS DRIVE STE D
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807
Mailing Address - Country:US
Mailing Address - Phone:563-355-0015
Mailing Address - Fax:563-355-0013
Practice Address - Street 1:4624 PROGRESS DRIVE STE D
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807
Practice Address - Country:US
Practice Address - Phone:563-355-0015
Practice Address - Fax:563-355-0013
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-115671207N00000X
IL036115671207R00000X
IA36638207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036115671Medicaid
IA0744987Medicaid
IL036115671Medicaid
IA1922047869Medicaid
IAI18950Medicare PIN
IAI18949Medicare PIN
IL200715013Medicare PIN
IA719260431Medicare PIN
IAH95829Medicare UPIN
ILX76440Medicare UPIN