Provider Demographics
NPI:1013086560
Name:RAVANBAKHSH, AZITA (MD)
Entity type:Individual
Prefix:DR
First Name:AZITA
Middle Name:
Last Name:RAVANBAKHSH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AZITA
Other - Middle Name:
Other - Last Name:MOOSAVY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:33 WESTWOOD BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:HOCKESSIN
Mailing Address - State:DE
Mailing Address - Zip Code:19707
Mailing Address - Country:US
Mailing Address - Phone:302-352-1719
Mailing Address - Fax:
Practice Address - Street 1:4755 OGLETOWN STANTON RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-5235
Practice Address - Country:US
Practice Address - Phone:026-230-1883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0008173174400000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEC1-0008173OtherMEDICAL LICENSE
DEMD5235OtherDEA
DEG02723I06Medicare PIN
DEMD5235OtherDEA