Healthcare Provider Details

I. General information

NPI: 1073544417
Provider Name (Legal Business Name): SHAHRAM F RAVAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 N BEDFORD DR SUITE 214
BEVERLY HILLS CA
90210-4310
US

IV. Provider business mailing address

436 N BEDFORD DR SUITE 214
BEVERLY HILLS CA
90210-4310
US

V. Phone/Fax

Practice location:
  • Phone: 310-858-9200
  • Fax: 310-271-3793
Mailing address:
  • Phone: 310-858-9200
  • Fax: 310-271-3793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA40168
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: