Provider Demographics
NPI:1114916376
Name:EBRAHIMI, SAM A (MD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:A
Last Name:EBRAHIMI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SAM
Other - Middle Name:
Other - Last Name:AFKHAM-EBRAHIMI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:18375 VENTURA BLVD
Mailing Address - Street 2:SUITE# 404
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-4218
Mailing Address - Country:US
Mailing Address - Phone:301-537-7751
Mailing Address - Fax:
Practice Address - Street 1:18375 VENTURA BLVD
Practice Address - Street 2:SUITE# 404
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-4218
Practice Address - Country:US
Practice Address - Phone:818-422-5322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2016-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD338062086S0129X
VA01012337422086S0129X
MDD00593182086S0129X
CAA060777208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
100336OtherJHHC PRIORITY PARTNER
DCJ449-0010OtherCAREFIRST
DC035556900Medicaid
4129526OtherMAMSI LIFE & HEALTH
MD484AWAOtherCAREFIRST MARYLAND
DCP00435744OtherRAILROAD MEDICARE
MD404465702Medicaid
DC035556900Medicaid
DCJ449-0010OtherCAREFIRST
DCG02731C02Medicare PIN