Provider Demographics
NPI:1902966443
Name:RAVICHANDRAN, LATHA M
Entity Type:Individual
Prefix:
First Name:LATHA
Middle Name:M
Last Name:RAVICHANDRAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1602 ROCK PRAIRIE STE. 230
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-2600
Mailing Address - Country:US
Mailing Address - Phone:979-693-2586
Mailing Address - Fax:
Practice Address - Street 1:1602 ROCK PRAIRIE RD STE 230
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8307
Practice Address - Country:US
Practice Address - Phone:979-693-2586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM5460207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000951607Medicaid
TX000951608Medicaid
TX741715140OtherTAX ID
TX154467803Medicaid
TX1649265646OtherNPI CLINIC
TX185649401Medicaid
TX154467801Medicaid
TX1821185299OtherNPI AGENCY
TX187842301Medicaid
TX451942Medicare Oscar/Certification
TX154467801Medicaid
TX000951608Medicaid
TX671848Medicare Oscar/Certification
TX187842301Medicaid
TX000951607Medicaid