Basic Information
| Provider Information | |||||||||
| NPI: | 1023063989 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GHAVAM | ||||||||
| FirstName: | CYRUS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 670 GLADES RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334316464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614959511 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5210 LINTON BLVD STE 304 | ||||||||
| Address2: | |||||||||
| City: | DELRAY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334846537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614959511 | ||||||||
| FaxNumber: | 5619907426 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MD61000908 | WA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0117X | 14668 | AL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207XS0117X | ME145684 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
| ID | Type | State | Issuer | Description | 009937579 | 05 | AL | MEDICAID | 4520495 | 01 | AL | AETNA | OTHER | 2149403 | 05 | WA | MEDICAID | P00338937 | 01 | AL | RAILROAD MEDICARE | OTHER | 51535248 | 01 | AL | BCBS | OTHER |