Provider Demographics
NPI:1639183569
Name:GHAHARI, FAKHRIRAN (MD)
Entity Type:Individual
Prefix:
First Name:FAKHRIRAN
Middle Name:
Last Name:GHAHARI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 E ANGELENO AVE
Mailing Address - Street 2:#102
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91501-2286
Mailing Address - Country:US
Mailing Address - Phone:818-845-6800
Mailing Address - Fax:818-843-7871
Practice Address - Street 1:421 E ANGELENO
Practice Address - Street 2:#102
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91501
Practice Address - Country:US
Practice Address - Phone:818-845-6800
Practice Address - Fax:818-843-7871
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55478207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A554780Medicaid
CAG24918Medicare UPIN
CA00A554780Medicaid