Provider Demographics
NPI:1144395443
Name:RAVANGARD, FIROOZ (MD)
Entity Type:Individual
Prefix:DR
First Name:FIROOZ
Middle Name:
Last Name:RAVANGARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1656 CHAMPLIN AVE STE 222
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-4830
Mailing Address - Country:US
Mailing Address - Phone:315-724-7734
Mailing Address - Fax:315-724-7816
Practice Address - Street 1:1656 CHAMPLIN AVE STE 222
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-4830
Practice Address - Country:US
Practice Address - Phone:315-724-7734
Practice Address - Fax:315-724-7816
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY147007207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00634280Medicaid
NYCC3937Medicare ID - Type Unspecified
NYB81996Medicare UPIN