Provider Demographics
NPI:1720513237
Name:RAGUNANTHAN, BRAVEEN (MD MPH)
Entity Type:Individual
Prefix:
First Name:BRAVEEN
Middle Name:
Last Name:RAGUNANTHAN
Suffix:
Gender:M
Credentials:MD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 MARTIN LUTHER KING ST
Mailing Address - Street 2:
Mailing Address - City:MOUND BAYOU
Mailing Address - State:MS
Mailing Address - Zip Code:38762-9314
Mailing Address - Country:US
Mailing Address - Phone:662-741-8800
Mailing Address - Fax:
Practice Address - Street 1:702 MARTIN LUTHER KING ST
Practice Address - Street 2:
Practice Address - City:MOUND BAYOU
Practice Address - State:MS
Practice Address - Zip Code:38762-9314
Practice Address - Country:US
Practice Address - Phone:662-741-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-23
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS28758208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty