Provider Demographics
NPI:1861447906
Name:RAVICHANDRAN, THULASIRAMAN P (MD)
Entity type:Individual
Prefix:
First Name:THULASIRAMAN
Middle Name:P
Last Name:RAVICHANDRAN
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 1:2025 W OKLAHOMA AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-4455
Mailing Address - Country:US
Mailing Address - Phone:414-382-8960
Mailing Address - Fax:414-382-8975
Practice Address - Street 1:2025 W OKLAHOMA AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4455
Practice Address - Country:US
Practice Address - Phone:414-382-8960
Practice Address - Fax:414-382-8975
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38984-202084D0003X
WI38984-0202084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084D0003XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyDiagnostic Neuroimaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI130020975OtherRAILROAD MEDICARE
WI32352600Medicaid
WI000002001Medicare PIN
F95411Medicare UPIN