Provider Demographics
NPI:1639111842
Name:RAVICH, WILLIAM J (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:RAVICH
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 1:40 TEMPLE ST STE 1A
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-2715
Mailing Address - Country:US
Mailing Address - Phone:203-785-4138
Mailing Address - Fax:203-737-1345
Practice Address - Street 1:40 TEMPLE ST STE 1A
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-2715
Practice Address - Country:US
Practice Address - Phone:203-785-4138
Practice Address - Fax:203-737-1345
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT56910207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD317921400Medicaid
MDB68013Medicare UPIN
MDMI91Medicare ID - Type Unspecified
MD317921400Medicaid
MD251P528GMedicare PIN