Provider Demographics
NPI:1124114335
Name:RAVIN, SHELDON (DO)
Entity type:Individual
Prefix:
First Name:SHELDON
Middle Name:
Last Name:RAVIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4190 E WOODMEN RD STE 100
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-8075
Mailing Address - Country:US
Mailing Address - Phone:719-632-4455
Mailing Address - Fax:719-633-4613
Practice Address - Street 1:4190 E WOODMEN RD STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920
Practice Address - Country:US
Practice Address - Phone:719-632-4455
Practice Address - Fax:719-633-4613
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18863207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01188630Medicaid
74791Medicare ID - Type Unspecified
CO01188630Medicaid