1104214113 NPI number — KASRA NAVABI MD

Table of content: (NPI 1104214113)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104214113 NPI number — KASRA NAVABI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KASRA NAVABI MD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1104214113
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3217 N VERDUGO RD
Provider Second Line Business Mailing Address:
#2
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91208-1672
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-550-0702
Provider Business Mailing Address Fax Number:
818-550-0705

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3217 N VERDUGO RD
Provider Second Line Business Practice Location Address:
#2
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91208-1672
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-550-0702
Provider Business Practice Location Address Fax Number:
818-550-0705
Provider Enumeration Date:
12/26/2014

Additional Information

Authorized Official

Authorized Official Last Name:
NAVABI
Authorized Official First Name:
KASRA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
650-576-9944

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  MD2012-0589 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X , with the licence number: CA116768 , 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: A116768 . This is a "MEDICAL BOARD OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: MD2012-0589 . This is a "NEW MEXICO MEDICAL BOARD" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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