Provider Demographics
NPI:1447229570
Name:GANJIANPOUR, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GANJIANPOUR
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 1:6330 SAN VICENTE BLVD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5425
Mailing Address - Country:US
Mailing Address - Phone:310-855-0751
Mailing Address - Fax:310-358-2453
Practice Address - Street 1:6330 SAN VICENTE BLVD
Practice Address - Street 2:SUITE 310
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5425
Practice Address - Country:US
Practice Address - Phone:310-855-0751
Practice Address - Fax:310-358-2453
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71208207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00068539OtherRAILROAD MEDICARE
CA346434300OtherDEPT OF LABOR
CA00A712080Medicaid
CAP00068539OtherRAILROAD MEDICARE
CAH23810Medicare UPIN
CA6041870001Medicare NSC
CAA71208Medicare ID - Type Unspecified