Provider Demographics
NPI:1073813598
Name:MAZIAR GHODSIAN DO PC
Entity Type:Organization
Organization Name:MAZIAR GHODSIAN DO PC
Other - Org Name:PROCTOLOGY INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAZIAR
Authorized Official - Middle Name:
Authorized Official - Last Name:GHODSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:800-280-6384
Mailing Address - Street 1:300 S BEVERLY DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-4808
Mailing Address - Country:US
Mailing Address - Phone:800-280-6384
Mailing Address - Fax:
Practice Address - Street 1:300 S BEVERLY DR
Practice Address - Street 2:SUITE 105
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-4808
Practice Address - Country:US
Practice Address - Phone:800-280-6384
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-01
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A9722208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty