Provider Demographics
NPI:1457373623
Name:IRAVANI, ABDOLLAH NONE (MD)
Entity Type:Individual
Prefix:DR
First Name:ABDOLLAH
Middle Name:NONE
Last Name:IRAVANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 W SR 434
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-4980
Mailing Address - Country:US
Mailing Address - Phone:407-898-2811
Mailing Address - Fax:407-898-6044
Practice Address - Street 1:2106 N. ORANGE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32804
Practice Address - Country:US
Practice Address - Phone:407-898-2811
Practice Address - Fax:407-898-6044
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0031538174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL058637400Medicaid