Provider Demographics
NPI:1164467239
Name:MAZAHERI, ATA (MD)
Entity Type:Individual
Prefix:
First Name:ATA
Middle Name:
Last Name:MAZAHERI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:20911 EARL ST
Mailing Address - Street 2:STE 245
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-4355
Mailing Address - Country:US
Mailing Address - Phone:818-247-7600
Mailing Address - Fax:818-247-7126
Practice Address - Street 1:1560 E CHEVY CHASE DR
Practice Address - Street 2:SUITE 450
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4197
Practice Address - Country:US
Practice Address - Phone:818-246-3300
Practice Address - Fax:818-247-7600
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2016-05-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA79930208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A799300Medicaid
CAI38292Medicare UPIN
CA00A799300Medicaid