Provider Demographics
NPI:1669747903
Name:RAVUSSIN, JEREMY (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:RAVUSSIN
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 1:611 WATKINS CENTRE PKWY
Mailing Address - Street 2:SUITE 250
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-4404
Mailing Address - Country:US
Mailing Address - Phone:804-423-8470
Mailing Address - Fax:804-423-8471
Practice Address - Street 1:611 WATKINS CENTRE PKWY
Practice Address - Street 2:SUITE 250
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-4404
Practice Address - Country:US
Practice Address - Phone:804-423-8470
Practice Address - Fax:804-423-8471
Is Sole Proprietor?:No
Enumeration Date:2012-03-20
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101257793207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09633OtherGROUP PTAN