Basic Information
| Provider Information | |||||||||
| NPI: | 1558357319 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NIKRAVAN | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 355 PLACENTIA AVE | ||||||||
| Address2: | STE 99 | ||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926633301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9496500600 | ||||||||
| FaxNumber: | 8662930414 | ||||||||
| Practice Location | |||||||||
| Address1: | 355 PLACENTIA AVE | ||||||||
| Address2: | STE 99 | ||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926633301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9496500616 | ||||||||
| FaxNumber: | 9496500600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2005 | ||||||||
| LastUpdateDate: | 06/19/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | A80371 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | A80371 | 01 | CA | STATE LICENSE | OTHER |