Provider Demographics
NPI:1255421442
Name:RAVITZ, MARJORIE (DPM)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:
Last Name:RAVITZ
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 MIDDLE COUNTRY ROAD
Mailing Address - Street 2:STE 104
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787
Mailing Address - Country:US
Mailing Address - Phone:631-724-1166
Mailing Address - Fax:631-724-4130
Practice Address - Street 1:260 MIDDLE COUNTRY ROAD
Practice Address - Street 2:STE 104
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787
Practice Address - Country:US
Practice Address - Phone:631-724-1166
Practice Address - Fax:631-724-4130
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN4126213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4227812OtherAETNA
NY01470451Medicaid
NY0406805OtherGHI
NYP3916310OtherOXFORD
NY2420175005OtherCIGNA
NY6C7212OtherHEALTHNET
NYPM2951OtherBLUE CROSS
NY1C0990OtherHEALTHNET
NY36835POtherHIP
NY10645OtherVYTRA
NYCS989OtherOXFORD
NY1C0990OtherHEALTHNET
NY2420175005OtherCIGNA
NY01470451Medicaid
NYP3916310OtherOXFORD
T51397Medicare UPIN