Healthcare Provider Details

I. General information

NPI: 1154328656
Provider Name (Legal Business Name): SOHEIL GORAVANCHI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 01/24/2020
Certification Date: 01/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 W CHARLESTON BLVD
LAS VEGAS NV
89102-2179
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 702-877-8661
  • Fax: 702-667-4689
Mailing address:
  • Phone: 702-242-7199
  • Fax: 702-667-4689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number1059
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: