Provider Demographics
NPI:1518078732
Name:GHARAVI, RAD (MD)
Entity type:Individual
Prefix:
First Name:RAD
Middle Name:
Last Name:GHARAVI
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 1:6551 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1020
Mailing Address - Country:US
Mailing Address - Phone:708-790-5200
Mailing Address - Fax:708-524-2104
Practice Address - Street 1:6551 NORTH AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1020
Practice Address - Country:US
Practice Address - Phone:708-790-5200
Practice Address - Fax:708-524-2104
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-1033222084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3643828866061502Medicaid
IL3643828866061502Medicaid
ILH21982Medicare UPIN