Provider Demographics
NPI:1639234362
Name:BENJAMIN BEHROOZAN M D INC
Entity Type:Organization
Organization Name:BENJAMIN BEHROOZAN M D INC
Other - Org Name:GREAT CARE MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BEHROOZAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-396-9999
Mailing Address - Street 1:2221 LINCOLN BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-1320
Mailing Address - Country:US
Mailing Address - Phone:310-396-9999
Mailing Address - Fax:310-664-8901
Practice Address - Street 1:2221 LINCOLN BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-1320
Practice Address - Country:US
Practice Address - Phone:310-396-9999
Practice Address - Fax:310-664-8901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41374207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0026800Medicaid
CAGR0026800Medicaid
CAE98966Medicare UPIN