Provider Demographics
NPI:1558347674
Name:RAVERA, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:RAVERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:16100 SAND CANYON AVE
Mailing Address - Street 2:STE 240
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3724
Mailing Address - Country:US
Mailing Address - Phone:949-640-2081
Mailing Address - Fax:949-640-1909
Practice Address - Street 1:16100 SAND CANYON AVE
Practice Address - Street 2:STE 240
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3724
Practice Address - Country:US
Practice Address - Phone:949-640-2081
Practice Address - Fax:949-640-1909
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-20
Last Update Date:2020-02-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA333549208800000X
CAC28250208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC28250Medicare ID - Type Unspecified
A33569Medicare UPIN