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General NPI Number Information
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NPI Number | 1669121448
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Entity Type | Individual
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Provider Name | PAVITRA RAVISHANKAR MD
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Gender | Female
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Dates
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Enumeration Date | 03/21/2022
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Last Update Date | 03/21/2022
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Provider Practice Location Address
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Address Line | 1201 S GRAND BLVD
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City | SAINT LOUIS
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State | MO
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Zip | 63104-1016
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Country | US
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Telephone | 314-257-8000
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Fax |
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Provider Business Mailing Address
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Address Line | 34367 MIMOSA TER
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City | FREMONT
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State | CA
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Zip | 94555-1811
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Country | US
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Telephone | 510-579-1119
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Fax |
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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 | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number | NA
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License Number State | MO
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