Provider Demographics
NPI:1508136326
Name:SEPEHR KATIRAIE MD INC.
Entity Type:Organization
Organization Name:SEPEHR KATIRAIE MD INC.
Other - Org Name:SAN MIGUEL MEDICAL CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SEPEHR
Authorized Official - Middle Name:
Authorized Official - Last Name:KATIRAIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-588-3800
Mailing Address - Street 1:724 N ELM DR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-3423
Mailing Address - Country:US
Mailing Address - Phone:323-588-3800
Mailing Address - Fax:323-277-0399
Practice Address - Street 1:2625 E FLORENCE AVE STE D
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4756
Practice Address - Country:US
Practice Address - Phone:323-588-3800
Practice Address - Fax:323-277-0399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-10
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54478261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA54478Medicaid
CAA54478Medicaid