Provider Demographics
NPI:1063642528
Name:BOBBY GHANAVATI, MD PLLC
Entity Type:Organization
Organization Name:BOBBY GHANAVATI, MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HABIBOLLAH
Authorized Official - Middle Name:
Authorized Official - Last Name:GHANAVATI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-703-1766
Mailing Address - Street 1:9970 CENTRAL PARK BLVD N STE 207
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-2236
Mailing Address - Country:US
Mailing Address - Phone:561-703-1766
Mailing Address - Fax:
Practice Address - Street 1:9970 CENTRAL PARK BLVD N STE 207
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428
Practice Address - Country:US
Practice Address - Phone:561-482-1027
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-19
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME97136174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty