Provider Demographics
NPI:1487613535
Name:RAVAGO, LESLIE CHUA (MD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:CHUA
Last Name:RAVAGO
Suffix:
Gender:F
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:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6015 118TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244-3703
Practice Address - Country:US
Practice Address - Phone:904-633-0610
Practice Address - Fax:904-633-0611
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73649208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2522209-00Medicaid
GA000760647BMedicaid
GA000760647BMedicaid
FL2522209-00Medicaid