Provider Demographics
NPI:1841615762
Name:GRAVORI, PEYMAN
Entity Type:Individual
Prefix:
First Name:PEYMAN
Middle Name:
Last Name:GRAVORI
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 1:16311 VENTURA BLVD STE 1065-B
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2124
Mailing Address - Country:US
Mailing Address - Phone:310-278-7000
Mailing Address - Fax:310-321-4510
Practice Address - Street 1:16311 VENTURA BLVD STE 1065-B
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2124
Practice Address - Country:US
Practice Address - Phone:310-278-7000
Practice Address - Fax:310-321-4510
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-28
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14719208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty