Healthcare Provider Details

I. General information

NPI: 1669571238
Provider Name (Legal Business Name): MARK DOUGLAS RAVENSCRAFT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 10/01/2023
Certification Date: 10/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1753 STIFEL LANE DR
TOWN AND COUNTRY MO
63017-8048
US

IV. Provider business mailing address

1753 STIFEL LANE DR
TOWN AND COUNTRY MO
63017-8048
US

V. Phone/Fax

Practice location:
  • Phone: 314-439-5113
  • Fax:
Mailing address:
  • Phone: 314-439-5113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberR4F85
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: