Provider Demographics
NPI:1417102229
Name:RAVIPATI, GOWTAM (MD)
Entity type:Individual
Prefix:
First Name:GOWTAM
Middle Name:
Last Name:RAVIPATI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GAUTHAM
Other - Middle Name:
Other - Last Name:RAVIPATI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2500 N HOUSTON ST APT 2202
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-7665
Mailing Address - Country:US
Mailing Address - Phone:914-625-5375
Mailing Address - Fax:
Practice Address - Street 1:2500 N HOUSTON ST APT 2202
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-7665
Practice Address - Country:US
Practice Address - Phone:914-625-5375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-20
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236440207RC0000X
TXP4372207RC0000X
WI69644207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX272398YKPWMedicare PIN
TX272398YKP5Medicare PIN
TX272398YKQLMedicare PIN