Provider Demographics
NPI:1962490169
Name:RAVIPATI, MAMATA (MD)
Entity Type:Individual
Prefix:DR
First Name:MAMATA
Middle Name:
Last Name:RAVIPATI
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 1:3537 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0035
Mailing Address - Country:US
Mailing Address - Phone:708-786-2900
Mailing Address - Fax:
Practice Address - Street 1:3471 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-3090
Practice Address - Country:US
Practice Address - Phone:847-473-4357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-104010207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-104010-2Medicaid
IL036-104010-2Medicaid
ILK16102/357801Medicare ID - Type Unspecified