Basic Information
| Provider Information | |||||||||
| NPI: | 1700081080 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAVIENDRAN | ||||||||
| FirstName: | RAVEEN | ||||||||
| MiddleName: | THEKKEURIMBIL | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3626 RUFFIN RD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585659666 | ||||||||
| FaxNumber: | 8585659441 | ||||||||
| Practice Location | |||||||||
| Address1: | 3626 RUFFIN RD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585659666 | ||||||||
| FaxNumber: | 8585659441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 08/22/2013 | ||||||||
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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 | 208000000X | A 108610 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0203X | A 108610 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1700081080 | 05 | CA | MEDICAID |