Provider Demographics
NPI:1871560896
Name:RAVI, MANOJ (MD)
Entity type:Individual
Prefix:DR
First Name:MANOJ
Middle Name:
Last Name:RAVI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:6599 TITAN PARK
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-0229
Mailing Address - Country:US
Mailing Address - Phone:602-510-3748
Mailing Address - Fax:
Practice Address - Street 1:JBSA-RANDOLPH CLINIC 559 MEDICAL SQUADRON
Practice Address - Street 2:221 3RD ST W
Practice Address - City:RANDOLPH AFB
Practice Address - State:TX
Practice Address - Zip Code:78150
Practice Address - Country:US
Practice Address - Phone:210-652-4264
Practice Address - Fax:210-652-4264
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXQ0814207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ0814OtherTEXAS MEDICAL BOARD
VA010158360OtherSTATE MEDICAL LICENSE
ARE-8688OtherSTATE LICENSE ARKANSAS
PAMD061431YOtherSTATE LICENSE