Healthcare Provider Details

I. General information

NPI: 1982698445
Provider Name (Legal Business Name): RAVI PRAKASH MD., FAAP DABP MRCP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 10/22/2008
Certification Date:
Deactivation Date: 03/25/2006
Reactivation Date: 04/03/2006

III. Provider practice location address

80 SHERMAN ST
NORWICH CT
06360-4106
US

IV. Provider business mailing address

80 SHERMAN ST
NORWICH CT
06360-4106
US

V. Phone/Fax

Practice location:
  • Phone: 860-886-0202
  • Fax: 860-886-5068
Mailing address:
  • Phone: 860-886-0202
  • Fax: 860-886-5068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number035836
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: