1770993347 NPI number — MEHDI F DERAMBKHSH MD INC

Table of content: (NPI 1770993347)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770993347 NPI number — MEHDI F DERAMBKHSH MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEHDI F DERAMBKHSH 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:
PHYSICIANS CHOICE DERMATOLOGY
Provider Other Organization Name Type Code:
3
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:
1770993347
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2474
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALOS VERDES PENINSULA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90274-8474
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-542-3439
Provider Business Mailing Address Fax Number:
888-505-0789

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3500 S BRISTOL ST
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
SANTA ANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92704-7319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-542-3439
Provider Business Practice Location Address Fax Number:
888-505-0789
Provider Enumeration Date:
05/05/2014

Additional Information

Authorized Official

Authorized Official Last Name:
DERAMBAKHSH
Authorized Official First Name:
MEHDI
Authorized Official Middle Name:
FARSHAD
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
310-218-6415

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  A88950 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ND0101X , with the licence number: A88950 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: A88950 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





Copyright © 2007-2024 www.npivalidator.com