Provider Demographics
NPI:1306880976
Name:IRAVANI, MARC (MD)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:IRAVANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MOHAMAD
Other - Middle Name:
Other - Last Name:IRAVANI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:757 WESTWOOD PLZ STE 3325
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3075
Practice Address - Country:US
Practice Address - Phone:310-267-8626
Practice Address - Fax:310-267-3899
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71342207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A713420Medicaid
CA00A713420OtherBLUE SHIELD OF CA
CAWA71342AMedicare ID - Type Unspecified
CA00A713420Medicaid