Provider Demographics
NPI:1972384196
Name:RAVI, PRIYANKA (MD,FRCPC)
Entity type:Individual
Prefix:
First Name:PRIYANKA
Middle Name:
Last Name:RAVI
Suffix:
Gender:F
Credentials:MD,FRCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 KENMONT RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63124-1022
Mailing Address - Country:US
Mailing Address - Phone:314-417-9510
Mailing Address - Fax:
Practice Address - Street 1:1402 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1004
Practice Address - Country:US
Practice Address - Phone:314-417-9510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023012592207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic PathologyGroup - Single Specialty