Provider Demographics
NPI:1922039478
Name:KHORSAND-RAVAN, FARIBORZ (MD)
Entity Type:Individual
Prefix:DR
First Name:FARIBORZ
Middle Name:
Last Name:KHORSAND-RAVAN
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 1:88 WASHINGTON ST
Mailing Address - Street 2:C/O MORTON HOSPITAL
Mailing Address - City:TAUNTON
Mailing Address - State:MA
Mailing Address - Zip Code:02780-2465
Mailing Address - Country:US
Mailing Address - Phone:508-824-1280
Mailing Address - Fax:508-824-7293
Practice Address - Street 1:88 WASHINGTON ST
Practice Address - Street 2:C/O MORTON HOSPITAL
Practice Address - City:TAUNTON
Practice Address - State:MA
Practice Address - Zip Code:02780-2465
Practice Address - Country:US
Practice Address - Phone:508-824-1280
Practice Address - Fax:508-824-7293
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD9948207V00000X
MA75558207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7008253Medicaid
RI7008253Medicaid