Provider Demographics
NPI:1194786426
Name:KASRAVI, BABAK (MD)
Entity type:Individual
Prefix:DR
First Name:BABAK
Middle Name:
Last Name:KASRAVI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91188-0001
Mailing Address - Country:US
Mailing Address - Phone:626-405-7914
Mailing Address - Fax:626-405-6768
Practice Address - Street 1:1188 N EUCLID ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-1900
Practice Address - Country:US
Practice Address - Phone:888-505-0043
Practice Address - Fax:626-405-6768
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71710174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A717100Medicaid
H77973Medicare UPIN
CAWA71710FMedicare ID - Type Unspecified