Provider Demographics
NPI:1578777033
Name:SOHREVARDI, MAHTAB (MD)
Entity Type:Individual
Prefix:DR
First Name:MAHTAB
Middle Name:
Last Name:SOHREVARDI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9400 BRIGHTON WAY
Mailing Address - Street 2:STE 410
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4711
Mailing Address - Country:US
Mailing Address - Phone:312-942-6163
Mailing Address - Fax:312-563-2096
Practice Address - Street 1:55 E CALIFORNIA BLVD STE 204
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3954
Practice Address - Country:US
Practice Address - Phone:626-397-8323
Practice Address - Fax:626-792-3611
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5400601-1205207RE0101X
CAC149677207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTBS8617687OtherDEA NUMBER