Provider Demographics
NPI:1609163815
Name:NAGRAJ, RAVI JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:RAVI
Middle Name:JOSEPH
Last Name:NAGRAJ
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 1:639 E OCEAN AVE STE 409
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-5017
Mailing Address - Country:US
Mailing Address - Phone:561-735-6553
Mailing Address - Fax:
Practice Address - Street 1:600 S DIXIE HWY STE 103
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-6034
Practice Address - Country:US
Practice Address - Phone:561-430-3629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-08
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT199338207R00000X
PAMD452483207R00000X
FLME146192207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108843400Medicaid