Provider Demographics
NPI:1114369055
Name:RAVI, NIVALI (MD)
Entity type:Individual
Prefix:DR
First Name:NIVALI
Middle Name:
Last Name:RAVI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 551308
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32255-1308
Mailing Address - Country:US
Mailing Address - Phone:904-622-9035
Mailing Address - Fax:904-493-2222
Practice Address - Street 1:665 STATE ROAD 207
Practice Address - Street 2:SUITE 102
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-5938
Practice Address - Country:US
Practice Address - Phone:904-824-8158
Practice Address - Fax:904-823-1284
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME120790207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013614500Medicaid
FL013614500Medicaid