Provider Demographics
NPI:1285602698
Name:GHARAVI, MOHAMMAD ALI (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:ALI
Last Name:GHARAVI
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 1:2190 LYNN RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360
Mailing Address - Country:US
Mailing Address - Phone:805-495-8050
Mailing Address - Fax:805-496-2160
Practice Address - Street 1:16255 VENTURA BLVD
Practice Address - Street 2:SUITE 910
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436
Practice Address - Country:US
Practice Address - Phone:818-990-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA302002086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A302000Medicaid
CA00A302000Medicaid
CAWA30200EMedicare PIN
WA30200DMedicare ID - Type Unspecified
WA30200CMedicare ID - Type Unspecified