Healthcare Provider Details

I. General information

NPI: 1871871053
Provider Name (Legal Business Name): PRAVIN RAVI DATE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2011
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27141 HIDAWAY AVE STE 106
CANYON COUNTRY CA
91351-4135
US

IV. Provider business mailing address

27141 HIDAWAY AVE STE 106
CANYON COUNTRY CA
91351-4135
US

V. Phone/Fax

Practice location:
  • Phone: 661-803-4824
  • Fax:
Mailing address:
  • Phone: 661-252-8469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberA147458
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA147458
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: