Basic Information
| Provider Information | |||||||||
| NPI: | 1104027390 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANGAVALLI | ||||||||
| FirstName: | RAVI | ||||||||
| MiddleName: | VENKATA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 285 DAVIDSON AVE | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | SOMERSET | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088734153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322711400 | ||||||||
| FaxNumber: | 7322713544 | ||||||||
| Practice Location | |||||||||
| Address1: | 285 DAVIDSON AVE | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | SOMERSET | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088734153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322711400 | ||||||||
| FaxNumber: | 7322713544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 05/01/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MA08271700 | NJ | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | MA08271700 | NJ | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.