Provider Demographics
NPI:1225526718
Name:HESHMATIPOUR, BAHRAM
Entity Type:Individual
Prefix:
First Name:BAHRAM
Middle Name:
Last Name:HESHMATIPOUR
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 1:23245 W VAIL DR
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-1449
Mailing Address - Country:US
Mailing Address - Phone:949-514-7728
Mailing Address - Fax:
Practice Address - Street 1:5353 BALBOA BLVD
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-2804
Practice Address - Country:US
Practice Address - Phone:818-387-6565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17592171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist