Basic Information
| Provider Information | |||||||||
| NPI: | 1588169817 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAVENBORG | ||||||||
| FirstName: | NOAH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5767 W CENTURY BLVD STE 400 | ||||||||
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| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900455631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103018771 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2020 SANTA MONICA BLVD STE 210 | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105826200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2018 | ||||||||
| LastUpdateDate: | 08/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | CA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | A165187 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.