Provider Demographics
NPI:1245465541
Name:RAVULA, SHANTAN BHARGAV REDD (MD)
Entity type:Individual
Prefix:DR
First Name:SHANTAN BHARGAV REDD
Middle Name:
Last Name:RAVULA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 ASHLAKE PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-2827
Mailing Address - Country:US
Mailing Address - Phone:804-256-8282
Mailing Address - Fax:804-256-8288
Practice Address - Street 1:7300 ASHLAKE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-2827
Practice Address - Country:US
Practice Address - Phone:804-256-8282
Practice Address - Fax:804-256-8288
Is Sole Proprietor?:No
Enumeration Date:2009-05-16
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA206173207QS1201X
VA0101273073207QS1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2348019Medicaid
LA2348019Medicaid