Healthcare Provider Details

I. General information

NPI: 1396858965
Provider Name (Legal Business Name): JOHN M RAVITS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 08/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 GILMAN DR MC 0624
LA JOLLA CA
92093-5004
US

IV. Provider business mailing address

9500 GILMAN DR MC 0624
LA JOLLA CA
92093-5004
US

V. Phone/Fax

Practice location:
  • Phone: 858-246-1154
  • Fax:
Mailing address:
  • Phone: 858-246-1154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberG43695
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberG43695
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License NumberG43695
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: