Provider Demographics
NPI:1053650762
Name:RICHARD F. GRAVINA, M.D. A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:RICHARD F. GRAVINA, M.D. A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:GRAVINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-348-6811
Mailing Address - Street 1:333 N. SAN MATEO DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401
Mailing Address - Country:US
Mailing Address - Phone:650-348-6811
Mailing Address - Fax:650-348-3651
Practice Address - Street 1:333 N. SAN MATEO DRIVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401
Practice Address - Country:US
Practice Address - Phone:650-348-6811
Practice Address - Fax:650-348-3651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-01
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00G2444502084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA42265Medicare UPIN