Healthcare Provider Details

I. General information

NPI: 1396030763
Provider Name (Legal Business Name): EMILIA RAVSKI D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2011
Last Update Date: 02/17/2020
Certification Date: 02/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 CORPORATE PLAZA DR
NEWPORT BEACH CA
92660-7985
US

IV. Provider business mailing address

22 CORPORATE PLAZA DR
NEWPORT BEACH CA
92660-7985
US

V. Phone/Fax

Practice location:
  • Phone: 949-722-7038
  • Fax: 949-630-4900
Mailing address:
  • Phone: 949-722-7038
  • Fax: 949-630-4900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number20A11920
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: