Provider Demographics
NPI:1871175174
Name:KARTHIKEYAN, RAVEENA (MBBS)
Entity type:Individual
Prefix:MS
First Name:RAVEENA
Middle Name:
Last Name:KARTHIKEYAN
Suffix:
Gender:F
Credentials:MBBS
Other - Prefix:MS
Other - First Name:RAVEENA
Other - Middle Name:
Other - Last Name:K
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 19638
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9638
Mailing Address - Country:US
Mailing Address - Phone:217-545-4401
Mailing Address - Fax:
Practice Address - Street 1:701 N 1ST, SUITE D308
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702
Practice Address - Country:US
Practice Address - Phone:215-481-7320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-26
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL125.079844208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program