Healthcare Provider Details

I. General information

NPI: 1306873922
Provider Name (Legal Business Name): RAVINDER R. KADEVARI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5192 HOSPITAL RD
MARIPOSA CA
95338-9524
US

IV. Provider business mailing address

PO BOX 939
ANGELS CAMP CA
95222-0939
US

V. Phone/Fax

Practice location:
  • Phone: 209-742-6144
  • Fax: 209-754-6274
Mailing address:
  • Phone: 209-754-6251
  • Fax: 209-754-6274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA52443
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: