Provider Demographics
NPI:1235217605
Name:GRAVINA, RICHARD FRANK (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:FRANK
Last Name:GRAVINA
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 1:333 N SAN MATEO DR
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401
Mailing Address - Country:US
Mailing Address - Phone:650-348-6811
Mailing Address - Fax:650-348-3651
Practice Address - Street 1:333 N SAN MATEO DR
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401
Practice Address - Country:US
Practice Address - Phone:650-348-6811
Practice Address - Fax:650-348-3651
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG244452084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G244450Medicare PIN
00G244450Medicare ID - Type Unspecified
A42265Medicare UPIN