Provider Demographics
NPI:1174659767
Name:IRAVANI, LEILA M (MD)
Entity Type:Individual
Prefix:
First Name:LEILA
Middle Name:M
Last Name:IRAVANI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 AVOCADO AVE STE 709
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-8714
Mailing Address - Country:US
Mailing Address - Phone:949-759-1720
Mailing Address - Fax:949-759-1442
Practice Address - Street 1:1401 AVOCADO AVE STE 709
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-8714
Practice Address - Country:US
Practice Address - Phone:949-759-1720
Practice Address - Fax:949-759-1442
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA56395208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A563950Medicaid