Provider Demographics
NPI:1295932549
Name:RAVI PACHIGOLLA MD PSC
Entity type:Organization
Organization Name:RAVI PACHIGOLLA MD PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RAVI
Authorized Official - Middle Name:V
Authorized Official - Last Name:PACHIGOLLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-596-8637
Mailing Address - Street 1:2016 FORT WORTH HWY
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-4706
Mailing Address - Country:US
Mailing Address - Phone:817-596-8637
Mailing Address - Fax:817-599-3614
Practice Address - Street 1:2016 FORT WORTH HWY
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-4706
Practice Address - Country:US
Practice Address - Phone:817-596-8637
Practice Address - Fax:817-599-3614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4763207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00Z738OtherMEDICARE GROUP PIN
1295932549OtherGROUP NPI #
KY64071855Medicaid
TX198437901OtherMEDICAID GRP PIN#
KY38283OtherLICENSE NUMBER
TXK4763OtherTEXAS LICENSE
TX198438701Medicaid
KY64071855Medicaid
TX198438701Medicaid