Healthcare Provider Details

I. General information

NPI: 1114369055
Provider Name (Legal Business Name): NIVALI RAVI M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2013
Last Update Date: 06/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 STATE ROAD 207 SUITE 102
ST AUGUSTINE FL
32084-5938
US

IV. Provider business mailing address

PO BOX 551308
JACKSONVILLE FL
32255-1308
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-8158
  • Fax: 904-823-1284
Mailing address:
  • Phone: 904-622-9035
  • Fax: 904-493-2222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME120790
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: