Healthcare Provider Details

I. General information

NPI: 1811678139
Provider Name (Legal Business Name): RAVI SHANKAR RANGANATHA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2023
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 MARTIN SPRINGS DR STE 230
ROLLA MO
65401-2980
US

IV. Provider business mailing address

1605 MARTIN SPRINGS DR STE 230
ROLLA MO
65401-2980
US

V. Phone/Fax

Practice location:
  • Phone: 573-458-6326
  • Fax:
Mailing address:
  • Phone: 573-458-6326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2026030861
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: