Healthcare Provider Details

I. General information

NPI: 1558464776
Provider Name (Legal Business Name): RAVI NISTALA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 09/02/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 HOSPITAL DRIVE
COLUMBIA MO
65212-0001
US

IV. Provider business mailing address

PO BOX 7687
COLUMBIA MO
65205-7687
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-8788
  • Fax: 573-882-3131
Mailing address:
  • Phone: 573-882-2259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2009007875
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number2009007875
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: