Provider Demographics
NPI:1568660090
Name:GHANAVATI, HABIBOLLAH (MD)
Entity Type:Individual
Prefix:
First Name:HABIBOLLAH
Middle Name:
Last Name:GHANAVATI
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 1:771 NE 36TH ST
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6137
Mailing Address - Country:US
Mailing Address - Phone:561-703-1766
Mailing Address - Fax:
Practice Address - Street 1:9970 CENTRAL PARK BLVD N STE 207
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428-2236
Practice Address - Country:US
Practice Address - Phone:561-703-1766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
FLME971362084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist