Provider Demographics
NPI:1376963033
Name:JOUKAR, MEHRDAD
Entity Type:Individual
Prefix:
First Name:MEHRDAD
Middle Name:
Last Name:JOUKAR
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 1:428 W CALIFORNIA AVE UNIT 108
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-4110
Mailing Address - Country:US
Mailing Address - Phone:818-244-8875
Mailing Address - Fax:818-244-1703
Practice Address - Street 1:411 N CENTRAL AVE
Practice Address - Street 2:#610
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-2052
Practice Address - Country:US
Practice Address - Phone:818-244-6792
Practice Address - Fax:818-244-1703
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15905171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist