Healthcare Provider Details

I. General information

NPI: 1710212147
Provider Name (Legal Business Name): PAVAN MAHENDRA RAVELLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2009
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 MEDICAL PARK RD STE 101
MOORESVILLE NC
28117-8541
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 980-302-7070
  • Fax:
Mailing address:
  • Phone: 980-302-7070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number2025-03697
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number01075948A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number01075948A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: