Provider Demographics
NPI:1518159730
Name:MEHRAN NOWFAR-RAD, M.D., INC.
Entity Type:Organization
Organization Name:MEHRAN NOWFAR-RAD, M.D., INC.
Other - Org Name:REGENCY DERMATOLOGY, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MEHRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NOWFAR-RAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-990-9665
Mailing Address - Street 1:5400 BALBOA BLVD
Mailing Address - Street 2:SUITE # 217
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-1502
Mailing Address - Country:US
Mailing Address - Phone:818-990-9665
Mailing Address - Fax:
Practice Address - Street 1:5400 BALBOA BLVD
Practice Address - Street 2:SUITE # 217
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1502
Practice Address - Country:US
Practice Address - Phone:818-990-9665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-11
Last Update Date:2007-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66360207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH44530Medicare UPIN