Healthcare Provider Details

I. General information

NPI: 1487810305
Provider Name (Legal Business Name): RAVI CHANDRA PULIPATI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2008
Last Update Date: 11/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 MEDFORD AVE SUITE A
PATCHOGUE NY
11772-1222
US

IV. Provider business mailing address

33 MEDFORD AVE SUITE A
PATCHOGUE NY
11772-1222
US

V. Phone/Fax

Practice location:
  • Phone: 631-569-5410
  • Fax: 631-569-5413
Mailing address:
  • Phone: 631-569-5410
  • Fax: 631-569-5413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number224728
License Number StateNY

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: