Healthcare Provider Details

I. General information

NPI: 1447645445
Provider Name (Legal Business Name): ETHAN RAVETCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 05/21/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 WATERS PLACE TOWER 1, 7TH FLOOR
BRONX NY
10461
US

IV. Provider business mailing address

1468 MADISON AVE
NEW YORK NY
10029-6508
US

V. Phone/Fax

Practice location:
  • Phone: 929-246-6300
  • Fax:
Mailing address:
  • Phone: 212-241-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number290370
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: