Provider Demographics
NPI:1659311991
Name:MARAVALLI, CAMILLE J (MD)
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:J
Last Name:MARAVALLI
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:PO BOX 580
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15907-0580
Mailing Address - Country:US
Mailing Address - Phone:814-536-5343
Mailing Address - Fax:814-536-1525
Practice Address - Street 1:120 MAIN ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15901-1507
Practice Address - Country:US
Practice Address - Phone:814-536-5343
Practice Address - Fax:814-536-1525
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD027329L207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B32916Medicare UPIN