Provider Demographics
NPI:1972860864
Name:DATE, ANIL RAVI (MD)
Entity Type:Individual
Prefix:
First Name:ANIL
Middle Name:RAVI
Last Name:DATE
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 1:27141 HIDAWAY AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91351-4135
Mailing Address - Country:US
Mailing Address - Phone:612-528-4696
Mailing Address - Fax:
Practice Address - Street 1:27141 HIDAWAY AVE STE 106
Practice Address - Street 2:
Practice Address - City:CANYON COUNTRY
Practice Address - State:CA
Practice Address - Zip Code:91351-4135
Practice Address - Country:US
Practice Address - Phone:818-220-5209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-16
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA125970207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine