Healthcare Provider Details

I. General information

NPI: 1912565490
Provider Name (Legal Business Name): SUGANTHI RAVINDRAN PHYSICIAN P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2019
Last Update Date: 05/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 HAWKINS AVE STE 1
LAKE RONKONKOMA NY
11779-2293
US

IV. Provider business mailing address

709 HAWKINS AVE STE 1
LAKE RONKONKOMA NY
11779-2293
US

V. Phone/Fax

Practice location:
  • Phone: 631-588-0880
  • Fax: 631-588-0391
Mailing address:
  • Phone: 631-588-0880
  • Fax: 631-588-0391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SUGANTHI RAVINDRAN
Title or Position: PRESIDENT
Credential: MD
Phone: 631-588-0880