Healthcare Provider Details

I. General information

NPI: 1255584769
Provider Name (Legal Business Name): LEILA M. IRAVANI, M.D., INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 10/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 NEWPORT BLVD SUITE 320
COSTA MESA CA
92627-3786
US

IV. Provider business mailing address

1640 NEWPORT BLVD SUITE 320
COSTA MESA CA
92627-3786
US

V. Phone/Fax

Practice location:
  • Phone: 949-261-7337
  • Fax:
Mailing address:
  • Phone: 949-261-7337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberA73865
License Number StateCA

VIII. Authorized Official

Name: DR. LEILA IRAVANI
Title or Position: CEO/PRESIDENT
Credential: M.D.
Phone: 714-881-4815