Provider Demographics
NPI:1609913441
Name:NEJAT ROSTAMI MEDICAL GROUP INC
Entity Type:Organization
Organization Name:NEJAT ROSTAMI MEDICAL GROUP INC
Other - Org Name:SAN JUDAS MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NEJAT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSTAMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-484-0000
Mailing Address - Street 1:2972 WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-1101
Mailing Address - Country:US
Mailing Address - Phone:213-484-0000
Mailing Address - Fax:213-387-0011
Practice Address - Street 1:2972 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-1101
Practice Address - Country:US
Practice Address - Phone:213-484-0000
Practice Address - Fax:213-387-0011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48731174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0055560Medicaid
CAGR0055560Medicaid