Provider Demographics
NPI:1962441873
Name:RAVISHANKAR, INDIRA (MD)
Entity Type:Individual
Prefix:
First Name:INDIRA
Middle Name:
Last Name:RAVISHANKAR
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 1:5 GEIGER LN
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:NJ
Mailing Address - Zip Code:07059-5639
Mailing Address - Country:US
Mailing Address - Phone:732-469-0241
Mailing Address - Fax:973-890-4574
Practice Address - Street 1:169 MINNISINK RD
Practice Address - Street 2:
Practice Address - City:TOTOWA
Practice Address - State:NJ
Practice Address - Zip Code:07512-1803
Practice Address - Country:US
Practice Address - Phone:973-256-1700
Practice Address - Fax:973-890-4574
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA3665600208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ834563B1JOtherMEDICARE BILLING
NJ4499701Medicaid
NJG21636Medicare UPIN