Provider Demographics
NPI:1770738825
Name:VEGASANA, RAVIKIRAN (MD)
Entity type:Individual
Prefix:
First Name:RAVIKIRAN
Middle Name:
Last Name:VEGASANA
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 1:608 E ORANGEBURG AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5513
Mailing Address - Country:US
Mailing Address - Phone:209-529-2645
Mailing Address - Fax:209-529-3024
Practice Address - Street 1:608 E ORANGEBURG AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5513
Practice Address - Country:US
Practice Address - Phone:209-529-2645
Practice Address - Fax:209-529-3024
Is Sole Proprietor?:No
Enumeration Date:2008-11-17
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35122842207RN0300X
CAA129459207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0103941Medicaid
CACA272453OtherMEDICARE