Provider Demographics
NPI:1376584698
Name:BROUKHIM, BIJAN (MD)
Entity Type:Individual
Prefix:
First Name:BIJAN
Middle Name:
Last Name:BROUKHIM
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 1:16311 VENTURA BLVD
Mailing Address - Street 2:SUITE 1080
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2124
Mailing Address - Country:US
Mailing Address - Phone:818-501-6775
Mailing Address - Fax:818-501-2723
Practice Address - Street 1:16311 VENTURA BLVD
Practice Address - Street 2:SUITE 1080
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2124
Practice Address - Country:US
Practice Address - Phone:818-501-6775
Practice Address - Fax:818-501-2723
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA29782174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A297820Medicaid
CAA84003Medicare UPIN
CA00A297820Medicaid