Healthcare Provider Details

I. General information

NPI: 1144214065
Provider Name (Legal Business Name): RAVI YADAVA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/25/2006
Reactivation Date: 05/01/2006

III. Provider practice location address

675 OLD BALLAS RD SUITE 210
SAINT LOUIS MO
63141-7083
US

IV. Provider business mailing address

675 OLD BALLAS RD SUITE 210
SAINT LOUIS MO
63141-7083
US

V. Phone/Fax

Practice location:
  • Phone: 314-994-9355
  • Fax: 314-994-0796
Mailing address:
  • Phone: 314-994-9355
  • Fax: 314-994-0796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number104036
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: