MEDICARE: DR. RAVI V PACHIGOLLA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207YX0602X	Otolaryngic Allergy Physician	K4763	TX
2	207Y00000X	Otolaryngology Physician	K4763	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00Z738	OTHER	TX	MEDICARE GROUP PIN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	K4763	OTHER	TX	TX LICENSE

General Provider Information

NPI Number	:	1396731402
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RAVI V PACHIGOLLA M.D.

Provider Business Mailing Address
First Line	:	2016 FORT WORTH HWY
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-4706
Country	:	US
Telephone Number	:	817-596-8637
Fax Number	:	855-217-1123

Provider Business Practice Location Address
First Line	:	2016 FORT WORTH HWY
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-4706
Country	:	US
Telephone Number	:	817-596-8637
Fax Number	:	855-217-1123

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/23/2005
Last Update Date	:	04/28/2022

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