Provider Demographics
NPI:1083969018
Name:P.B. NIKRAVESH DPM, APC
Entity Type:Organization
Organization Name:P.B. NIKRAVESH DPM, APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:YVETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:URETA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-782-8586
Mailing Address - Street 1:6404 WILSHIRE BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5501
Mailing Address - Country:US
Mailing Address - Phone:323-782-8586
Mailing Address - Fax:323-782-8528
Practice Address - Street 1:6404 WILSHIRE BLVD STE 600
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5501
Practice Address - Country:US
Practice Address - Phone:323-782-8586
Practice Address - Fax:323-782-8528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4103213EP1101X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E41032Medicaid
CAE4103OtherMEDICARE PTAN
CA000E41032Medicaid