Provider Demographics
NPI:1093478125
Name:METUSHI, IMIR
Entity Type:Individual
Prefix:
First Name:IMIR
Middle Name:
Last Name:METUSHI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6031 FOUNTAIN PARK LN APT 15
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-3525
Mailing Address - Country:US
Mailing Address - Phone:760-686-6282
Mailing Address - Fax:
Practice Address - Street 1:10833 LE CONTE AVE RM 231U
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3075
Practice Address - Country:US
Practice Address - Phone:760-686-6282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADRH-02018469246QC1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QC1000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyChemistry