Provider Demographics
NPI:1497700041
Name:KRAVETZ, TODD M (MD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:M
Last Name:KRAVETZ
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:PO BOX 271669
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-1669
Mailing Address - Country:US
Mailing Address - Phone:928-684-4383
Mailing Address - Fax:928-684-2434
Practice Address - Street 1:523 ROSE LN
Practice Address - Street 2:
Practice Address - City:WICKENBURG
Practice Address - State:AZ
Practice Address - Zip Code:85390-1448
Practice Address - Country:US
Practice Address - Phone:928-668-1833
Practice Address - Fax:926-684-7457
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35069162207R00000X
AZ34440207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ061483Medicaid
OH0238997Medicaid
OH0802947Medicare PIN