Provider Demographics
NPI:1306002761
Name:GHANDEHARI, JAVID (MD)
Entity Type:Individual
Prefix:
First Name:JAVID
Middle Name:
Last Name:GHANDEHARI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 W CIVIC CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-4284
Mailing Address - Country:US
Mailing Address - Phone:888-854-3822
Mailing Address - Fax:770-701-6673
Practice Address - Street 1:2121 WILSHIRE BLVD STE 201
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5742
Practice Address - Country:US
Practice Address - Phone:310-576-7267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125054209208600000X
CAA127144207L00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology