Provider Demographics
NPI:1669571238
Name:RAVENSCRAFT, MARK DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DOUGLAS
Last Name:RAVENSCRAFT
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 1:1753 STIFEL LANE DR
Mailing Address - Street 2:
Mailing Address - City:TOWN AND COUNTRY
Mailing Address - State:MO
Mailing Address - Zip Code:63017-8048
Mailing Address - Country:US
Mailing Address - Phone:314-439-5113
Mailing Address - Fax:
Practice Address - Street 1:1753 STIFEL LANE DR
Practice Address - Street 2:
Practice Address - City:TOWN AND COUNTRY
Practice Address - State:MO
Practice Address - Zip Code:63017-8048
Practice Address - Country:US
Practice Address - Phone:314-439-5113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2023-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4F85207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO110198407OtherRAILROAD MEDICARE
MO202897500Medicaid
MO002011536Medicare PIN
MO110198407OtherRAILROAD MEDICARE
E61451Medicare UPIN