Provider Demographics
NPI:1497820799
Name:FIROOZ RAVANGARD, MD PC
Entity Type:Organization
Organization Name:FIROOZ RAVANGARD, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FIROOZ
Authorized Official - Middle Name:
Authorized Official - Last Name:RAVANGARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-724-7734
Mailing Address - Street 1:1656 CHAMPLIN AVE STE 222
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-4830
Mailing Address - Country:US
Mailing Address - Phone:315-724-7734
Mailing Address - Fax:315-724-7816
Practice Address - Street 1:1656 CHAMPLIN AVE STE 222
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-4830
Practice Address - Country:US
Practice Address - Phone:315-724-7734
Practice Address - Fax:315-724-7816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY147007207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAA0742Medicare ID - Type Unspecified