Provider Demographics
NPI:1154328656
Name:GORAVANCHI, SOHEIL (DO)
Entity Type:Individual
Prefix:
First Name:SOHEIL
Middle Name:
Last Name:GORAVANCHI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:702-242-7199
Mailing Address - Fax:702-667-4689
Practice Address - Street 1:2450 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2179
Practice Address - Country:US
Practice Address - Phone:702-877-8661
Practice Address - Fax:702-667-4689
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1059207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2002163Medicaid
NV2002163Medicaid