=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699185371
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RAVID AVRAHAM PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2014
-----------------------------------------------------
Last Update Date | 05/02/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2828 LEMMON AVE APT 4154
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75204-3706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-284-3884
-----------------------------------------------------
Fax | 877-442-9313
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2828 LEMMON AVE APT 4154
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75204-3706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-284-3884
-----------------------------------------------------
Fax | 877-442-9313
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RAVID AVRAHAM
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 718-213-6543
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | P5928
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------