Provider Demographics
NPI:1952386112
Name:RAVURI, RAJESH (MD)
Entity type:Individual
Prefix:DR
First Name:RAJESH
Middle Name:
Last Name:RAVURI
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 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0000
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4505
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-0000
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-266-4505
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23904207RH0002X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR110233976OtherRR MEDICARE PTAN NUMBER
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
ORCD8723OtherRR MEDICARE GROUP NUMBER
OR1407812365OtherNBMC GROUP NPI NUMBER
OR286464Medicaid
OR930635514OtherGROUP TAX ID NUMBER
ORCD8723OtherRR MEDICARE GROUP NUMBER
OR1407812365OtherNBMC GROUP NPI NUMBER
ORH62548Medicare UPIN