Provider Demographics
NPI:1538228135
Name:GRAVELY, LANCE EUGENE (MD)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:EUGENE
Last Name:GRAVELY
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 1:39 CONGRESS ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3024
Mailing Address - Country:US
Mailing Address - Phone:323-221-1302
Mailing Address - Fax:323-221-1502
Practice Address - Street 1:50 ALESSANDRO PL STE 340
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3184
Practice Address - Country:US
Practice Address - Phone:323-221-1302
Practice Address - Fax:323-221-1502
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87871207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A878710Medicaid
I13702Medicare UPIN