Healthcare Provider Details

I. General information

NPI: 1154819613
Provider Name (Legal Business Name): RAVALI NAGOTHU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RAVALI KONDAVEETI MD

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 01/27/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14961 W BELL RD STE 175
SURPRISE AZ
85374-3220
US

IV. Provider business mailing address

14961 W BELL RD STE 175
SURPRISE AZ
85374-3220
US

V. Phone/Fax

Practice location:
  • Phone: 623-242-9830
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number73628
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number42885
License Number StateAL
# 4
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number73628
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: