Basic Information
| Provider Information | |||||||||
| NPI: | 1417154451 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAVI | ||||||||
| FirstName: | MALLESWARI | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 44008 | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322314008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042442120 | ||||||||
| FaxNumber: | 9042443425 | ||||||||
| Practice Location | |||||||||
| Address1: | 653-1 WEST 8TH STREET | ||||||||
| Address2: | 2ND FLOOR, LRC L14 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042443702 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2007 | ||||||||
| LastUpdateDate: | 12/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME104972 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | ME104972 | FL | N | Allopathic & Osteopathic Physicians | Hospitalist | 207RI0200X | ME104972 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 0037280-00 | 05 | FL | MEDICAID | 373978308 | 05 | FL | MEDICAID |