Provider Demographics
NPI:1124085840
Name:KRAVITZ, GARY ROBERT (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:ROBERT
Last Name:KRAVITZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1959 SLOAN PL
Mailing Address - Street 2:STE 200
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-2074
Mailing Address - Country:US
Mailing Address - Phone:651-772-6235
Mailing Address - Fax:651-772-6261
Practice Address - Street 1:1959 SLOAN PL
Practice Address - Street 2:STE 200
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55117-2074
Practice Address - Country:US
Practice Address - Phone:651-772-6235
Practice Address - Fax:651-772-6261
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN24327207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN899307600Medicaid
A96135Medicare UPIN
MN440000050Medicare ID - Type Unspecified