Provider Demographics
NPI:1881903656
Name:RAVIKUMAR, LEELMOHAN (MD,)
Entity type:Individual
Prefix:
First Name:LEELMOHAN
Middle Name:
Last Name:RAVIKUMAR
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:PO BOX 600
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-0600
Mailing Address - Country:US
Mailing Address - Phone:937-283-9699
Mailing Address - Fax:937-283-9839
Practice Address - Street 1:998 S DORSET RD STE 301
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-4748
Practice Address - Country:US
Practice Address - Phone:937-339-9865
Practice Address - Fax:937-339-6668
Is Sole Proprietor?:No
Enumeration Date:2010-09-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.122051207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0091133Medicaid