Provider Demographics
NPI:1851382246
Name:FIORAVANTI, BERNARD LOUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:LOUIS
Last Name:FIORAVANTI
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 1:1510 W 90TH ST N
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-8159
Mailing Address - Country:US
Mailing Address - Phone:918-686-5552
Mailing Address - Fax:918-683-4416
Practice Address - Street 1:1510 W 90TH ST N
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-8159
Practice Address - Country:US
Practice Address - Phone:918-519-1155
Practice Address - Fax:918-683-4416
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK117972085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100005620AMedicaid
OK100005620AMedicaid
OK245508301Medicare PIN
OKP00212734Medicare PIN