Provider Demographics
NPI:1871585521
Name:RAVICHANDRAN, NAGAMANIKKAM (MD, MBA, FACP)
Entity type:Individual
Prefix:DR
First Name:NAGAMANIKKAM
Middle Name:
Last Name:RAVICHANDRAN
Suffix:
Gender:M
Credentials:MD, MBA, FACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SHIRCLIFF WAY
Mailing Address - Street 2:SUITE 525
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4757
Mailing Address - Country:US
Mailing Address - Phone:904-389-3770
Mailing Address - Fax:904-389-3703
Practice Address - Street 1:3 SHIRCLIFF WAY
Practice Address - Street 2:SUITE 525
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4757
Practice Address - Country:US
Practice Address - Phone:904-389-3770
Practice Address - Fax:904-389-3703
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74104207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252904100Medicaid
FL42247AMedicare PIN
FL252904100Medicaid
G63712Medicare UPIN