Basic Information
| Provider Information | |||||||||
| NPI: | 1548466519 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAVID | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21942 EDGEWATER DR | ||||||||
| Address2: | |||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339529723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9415052100 | ||||||||
| FaxNumber: | 9415056100 | ||||||||
| Practice Location | |||||||||
| Address1: | 21942 EDGEWATER DR | ||||||||
| Address2: | |||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339529723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9415052100 | ||||||||
| FaxNumber: | 9415056100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2007 | ||||||||
| LastUpdateDate: | 06/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME 106244 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | E3121Y | 01 | FL | MEDICARE INDIVIDUAL | OTHER | 14C4Q | 01 | FL | BC/BS | OTHER | P01037543 | 01 | FL | RR MEDICARE | OTHER |