Provider Demographics
NPI:1205215944
Name:FARAZ MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:FARAZ MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:MOALLEMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-498-8250
Mailing Address - Street 1:1666 THAYER AVE
Mailing Address - Street 2:301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-6056
Mailing Address - Country:US
Mailing Address - Phone:310-498-8250
Mailing Address - Fax:323-796-0558
Practice Address - Street 1:3755 BEVERLY BLVD
Practice Address - Street 2:301
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-3539
Practice Address - Country:US
Practice Address - Phone:310-498-8250
Practice Address - Fax:323-796-0558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA112671207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty