Provider Demographics
NPI:1407007461
Name:RAVDEL, LARISA Y (MD)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:Y
Last Name:RAVDEL
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 1:1421 S POTOMAC ST STE 320
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-4512
Mailing Address - Country:US
Mailing Address - Phone:303-750-1920
Mailing Address - Fax:303-750-0483
Practice Address - Street 1:1421 S POTOMAC ST STE 320
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-4512
Practice Address - Country:US
Practice Address - Phone:303-750-1920
Practice Address - Fax:303-750-0483
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA40458208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1407007461Medicaid
IA1407007461Medicaid