Healthcare Provider Details

I. General information

NPI: 1578659819
Provider Name (Legal Business Name): SUGANTHI RAVINDRAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 09/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 HAWKINS AVE
RONKONKOMA NY
11779-2293
US

IV. Provider business mailing address

709 HAWKINS AVE
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 Number199922
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: