Provider Demographics
NPI:1659549400
Name:JOHN KAYVANFAR MD INC
Entity Type:Organization
Organization Name:JOHN KAYVANFAR MD INC
Other - Org Name:OLYMPIC ORTHOPEDIC MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KAYVENFAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-947-0078
Mailing Address - Street 1:PO BOX 260916
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91426-0916
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1224 E AVENUE S STE C
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-6180
Practice Address - Country:US
Practice Address - Phone:661-947-0078
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36821207R00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A368210Medicaid
CA00A368210Medicaid
CA0619940001Medicare NSC
CAD72100Medicare UPIN