Provider Demographics
NPI:1306041074
Name:IRAJ NAZARIAN MD, INC MEDICAL CLINIC
Entity Type:Organization
Organization Name:IRAJ NAZARIAN MD, INC MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IRAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:NAZARIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-991-4950
Mailing Address - Street 1:641 NORTH DOHENY DRIVE
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210
Mailing Address - Country:US
Mailing Address - Phone:310-991-4950
Mailing Address - Fax:323-249-0469
Practice Address - Street 1:7136 PACIFIC BLVD
Practice Address - Street 2:SUITE # 225
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4783
Practice Address - Country:US
Practice Address - Phone:310-991-4950
Practice Address - Fax:323-249-0469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43573305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA43573OtherLICENSE NUMBER
CABNO940925OtherDEA #
CAA43573OtherLICENSE NUMBER
CAA85888Medicare UPIN
CAA43573AMedicare ID - Type Unspecified