Provider Demographics
NPI:1255361242
Name:RAVISANKAR, PUNNAIVANAM (MD)
Entity type:Individual
Prefix:DR
First Name:PUNNAIVANAM
Middle Name:
Last Name:RAVISANKAR
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 1:2268 MANGOSIVE DRIVE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513
Mailing Address - Country:US
Mailing Address - Phone:859-296-9105
Mailing Address - Fax:
Practice Address - Street 1:222 MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1179
Practice Address - Country:US
Practice Address - Phone:606-783-6521
Practice Address - Fax:606-783-6904
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39446207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine