Healthcare Provider Details

I. General information

NPI: 1265764781
Provider Name (Legal Business Name): RAVI NALLAMOTHU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: RAVINDRA NATH NALLAMOTHU M.D.

II. Dates (important events)

Enumeration Date: 02/09/2010
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N CURTIS RD
BOISE ID
83706-1309
US

IV. Provider business mailing address

PO BOX 190930
BOISE ID
83719-0930
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-2000
  • Fax: 208-302-2055
Mailing address:
  • Phone: 208-367-5170
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberM-16901
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberC137072
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberC137072
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberM-16901
License Number StateID
# 5
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number2015-01967
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: