1487658811 NPI number — DR. ARDESHIR SOROUSHYARI M.D.

Table of content: DR. ARDESHIR SOROUSHYARI M.D. (NPI 1487658811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487658811 NPI number — DR. ARDESHIR SOROUSHYARI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOROUSHYARI
Provider First Name:
ARDESHIR
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487658811
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18370 BURBANK BLVD
Provider Second Line Business Mailing Address:
STE 601
Provider Business Mailing Address City Name:
TARZANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91356-2831
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-996-5700
Provider Business Mailing Address Fax Number:
818-996-1649

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18370 BURBANK BLVD
Provider Second Line Business Practice Location Address:
STE 601
Provider Business Practice Location Address City Name:
TARZANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91356-2831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-996-5700
Provider Business Practice Location Address Fax Number:
818-996-1649
Provider Enumeration Date:
06/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X , with the licence number:  A74069 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: YYY40048Y . This is a "BLUE SHIELD OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 110061982 . This is a "RAILROAD RENDERING NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: WA74069A . This is a "MEDICARE RENDERING NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 95-3132732 . This is a "BLUE CROSS OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: YYY40048Y , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: T0796 . This is a "RAILROAD GROUP NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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