Provider Demographics
NPI:1154431542
Name:RAVSTEN, DERIC V (DO)
Entity type:Individual
Prefix:DR
First Name:DERIC
Middle Name:V
Last Name:RAVSTEN
Suffix:
Gender:
Credentials:DO
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 1121
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0254
Mailing Address - Country:US
Mailing Address - Phone:541-672-2691
Mailing Address - Fax:877-284-2783
Practice Address - Street 1:621 W MADRONE ST STE 330
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3090
Practice Address - Country:US
Practice Address - Phone:541-672-2691
Practice Address - Fax:877-284-2783
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-2902084P0800X
ORDO2195712084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010154744OtherREGENCE BLUE SHIELD OF ID
IDS6444OtherBLUE CROSS OF IDAHO
ID806453300Medicaid
ID806453300Medicaid