Healthcare Provider Details

I. General information

NPI: 1174538995
Provider Name (Legal Business Name): RAVITHARAN KRISHNADASAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 01/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3838 N CAMPBELL AVE
TUCSON AZ
85719-1478
US

IV. Provider business mailing address

2701 E ELVIRA RD
TUCSON AZ
85756-7124
US

V. Phone/Fax

Practice location:
  • Phone: 520-694-2873
  • Fax: 520-694-1820
Mailing address:
  • Phone: 520-874-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number12173
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: