Provider Demographics
NPI:1407933484
Name:RAVITZ, STEPHEN BRADLEY (DPM)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:BRADLEY
Last Name:RAVITZ
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754
Mailing Address - Country:US
Mailing Address - Phone:631-269-4600
Mailing Address - Fax:631-269-0801
Practice Address - Street 1:63 MAIN STREET
Practice Address - Street 2:
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754
Practice Address - Country:US
Practice Address - Phone:631-269-4600
Practice Address - Fax:631-269-0801
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004798213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
19966OtherVYTRA
4C1647OtherHEALTHNET
6299184OtherGHI
NY01271269Medicaid
P55031OtherBLUE CROSS
C5267OtherOXFORD
NYP55031Medicare PIN
P55031OtherBLUE CROSS