Healthcare Provider Details

I. General information

NPI: 1174659767
Provider Name (Legal Business Name): LEILA M IRAVANI M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 AVOCADO AVE STE 709
NEWPORT BEACH CA
92660-8714
US

IV. Provider business mailing address

1401 AVOCADO AVE STE 709
NEWPORT BEACH CA
92660-8714
US

V. Phone/Fax

Practice location:
  • Phone: 949-759-1720
  • Fax: 949-759-1442
Mailing address:
  • Phone: 949-759-1720
  • Fax: 949-759-1442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA56395
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: