Healthcare Provider Details

I. General information

NPI: 1689789026
Provider Name (Legal Business Name): RAVI P NAYAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 05/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3660 VISTA AVE SUITE 202
SAINT LOUIS MO
63110-2540
US

IV. Provider business mailing address

1402 S GRAND BLVD MC / SLUH / 7FDT
SAINT LOUIS MO
63104-1004
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-6190
  • Fax: 314-977-5123
Mailing address:
  • Phone: 314-577-8856
  • Fax: 314-577-8859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number2000173750
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: