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General NPI Number Information
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NPI Number | 1245465541
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Entity Type | Individual
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Provider Name | SHANTAN BHARGAV REDD RAVULA MD
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Gender | Male
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Dates
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Enumeration Date | 05/16/2009
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Last Update Date | 10/19/2021
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Provider Practice Location Address
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Address Line | 7300 ASHLAKE PKWY STE 200
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City | CHESTERFIELD
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State | VA
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Zip | 23832-2827
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Country | US
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Telephone | 804-256-8282
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Fax | 804-256-8288
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Provider Business Mailing Address
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Address Line | 7300 ASHLAKE PKWY STE 200
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City | CHESTERFIELD
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State | VA
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Zip | 23832-2827
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Country | US
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Telephone | 804-256-8282
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Fax | 804-256-8288
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QS1201X
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Taxonomy Name | Sleep Medicine (Family Medicine) Physician
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License Number | 206173
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 207QS1201X
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Taxonomy Name | Sleep Medicine (Family Medicine) Physician
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License Number | 0101273073
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License Number State | VA
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