Provider Demographics
NPI:1508074352
Name:AMIRI, NOZAR (MD)
Entity Type:Individual
Prefix:DR
First Name:NOZAR
Middle Name:
Last Name:AMIRI
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 1:4174 WOODLEIGH LN
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91011-4057
Mailing Address - Country:US
Mailing Address - Phone:818-790-5261
Mailing Address - Fax:
Practice Address - Street 1:117 W CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-2211
Practice Address - Country:US
Practice Address - Phone:818-546-1688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA56376208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A563760Medicaid
CAG38703Medicare UPIN
CA00A563760Medicaid