Provider Demographics
NPI:1851851901
Name:RAVVIN, KONSTANTIN (MD)
Entity type:Individual
Prefix:DR
First Name:KONSTANTIN
Middle Name:
Last Name:RAVVIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 INDUSTRIAL RD STE 5
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01757-3736
Mailing Address - Country:US
Mailing Address - Phone:508-473-1480
Mailing Address - Fax:
Practice Address - Street 1:14 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-3003
Practice Address - Country:US
Practice Address - Phone:508-473-1480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-24
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1016008207R00000X
RIMD18885207R00000X, 208D00000X, 207R00000X
NHLT4397207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice