Healthcare Provider Details

I. General information

NPI: 1760503205
Provider Name (Legal Business Name): RAVI DANIEL THAMBURAJ DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 LYONS AVE
NEWARK NJ
07112-2027
US

IV. Provider business mailing address

1341 NORTH AVE APT 3K
ELIZABETH NJ
07208-2674
US

V. Phone/Fax

Practice location:
  • Phone: 973-926-7000
  • Fax: 973-923-2441
Mailing address:
  • Phone: 908-558-9414
  • Fax: 973-923-2441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MB07895600
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: