Basic Information
| Provider Information | |||||||||
| NPI: | 1104115963 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAVI | ||||||||
| FirstName: | SOWMYA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | RAVI | ||||||||
| OtherFirstName: | SOWMYA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15906 MILL CREEK BLVD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | MILL CREEK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980121797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253852009 | ||||||||
| FaxNumber: | 4259390807 | ||||||||
| Practice Location | |||||||||
| Address1: | 15906 MILL CREEK BLVD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | MILL CREEK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980121797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253852009 | ||||||||
| FaxNumber: | 4259390807 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2011 | ||||||||
| LastUpdateDate: | 08/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | MD606048465 | WA | N | Allopathic & Osteopathic Physicians | Dermatology | 207ND0101X | MD60648465 | WA | Y | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
No ID Information.