1104929777 NPI number — MICHAEL KERMANI, MD, INC

Table of content: (NPI 1104929777)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104929777 NPI number — MICHAEL KERMANI, MD, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL KERMANI, MD, INC
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:
6
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:
1104929777
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P O BOX 10711
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWPORT BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92658
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-640-2010
Provider Business Mailing Address Fax Number:
949-640-2090

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1441 AVOCADO AVE
Provider Second Line Business Practice Location Address:
SUITE 501
Provider Business Practice Location Address City Name:
NEWPORT BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92660-7721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-640-2010
Provider Business Practice Location Address Fax Number:
949-640-2090
Provider Enumeration Date:
09/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KERMANI
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
949-640-2010

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  A75009 , 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: 1013010685 . This is a "NPI PERSONAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00A750090 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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