Provider Demographics
NPI:1992232581
Name:PEYMAN GRAVORI, D.O. INC., A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:PEYMAN GRAVORI, D.O. INC., A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PEYMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAVORI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:310-278-7000
Mailing Address - Street 1:16311 VENTURA BLVD STE 1065-B
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2124
Mailing Address - Country:US
Mailing Address - Phone:310-278-7000
Mailing Address - Fax:
Practice Address - Street 1:16311 VENTURA BLVD STE 1065-B
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2124
Practice Address - Country:US
Practice Address - Phone:310-278-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A14719208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty