Provider Demographics
NPI:1265764781
Name:NALLAMOTHU, RAVI (MD)
Entity type:Individual
Prefix:DR
First Name:RAVI
Middle Name:
Last Name:NALLAMOTHU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:RAVI
Other - Middle Name:NATH
Other - Last Name:NALLAMOTHU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6 WOODLAND RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:SAINT HELENA
Mailing Address - State:CA
Mailing Address - Zip Code:94574-9501
Mailing Address - Country:US
Mailing Address - Phone:707-963-0267
Mailing Address - Fax:
Practice Address - Street 1:913 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CALISTOGA
Practice Address - State:CA
Practice Address - Zip Code:94515-1433
Practice Address - Country:US
Practice Address - Phone:707-942-6233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-16901207RC0200X
CAC137072207RC0200X, 207RP1001X
NC2015-01967207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1265764781Medicare UPIN