Provider Demographics
NPI:1679861553
Name:PRAVIN, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PRAVIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2385 ROSCOMARE RD
Mailing Address - Street 2:E-17
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1838
Mailing Address - Country:US
Mailing Address - Phone:323-350-3543
Mailing Address - Fax:
Practice Address - Street 1:2385 ROSCOMARE RD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90077-1838
Practice Address - Country:US
Practice Address - Phone:323-350-3543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-13
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography
No246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonography
No2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular Sonography