Provider Demographics
NPI:1104916998
Name:RAVENER, PAUL DAVID (DC)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:DAVID
Last Name:RAVENER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:298 CANAL RD.
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3020
Mailing Address - Country:US
Mailing Address - Phone:631-928-0192
Mailing Address - Fax:631-928-0253
Practice Address - Street 1:298 CANAL RD.
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-3020
Practice Address - Country:US
Practice Address - Phone:631-928-0192
Practice Address - Fax:631-928-0253
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3502111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
X19231Medicare PIN