Healthcare Provider Details

I. General information

NPI: 1972916484
Provider Name (Legal Business Name): RAVINDRA PERSAUD CSA LSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2014
Last Update Date: 06/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3543 SHAWN ST
PORT CHARLOTTE FL
33980-8660
US

IV. Provider business mailing address

3543 SHAWN ST
PORT CHARLOTTE FL
33980-8660
US

V. Phone/Fax

Practice location:
  • Phone: 470-295-7782
  • Fax:
Mailing address:
  • Phone: 470-295-7782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number3858
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: