Provider Demographics
NPI:1710955539
Name:TABIBIAN, BEHNAM SAM (MD)
Entity Type:Individual
Prefix:DR
First Name:BEHNAM
Middle Name:SAM
Last Name:TABIBIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11693 SAN VICENTE BLVD
Mailing Address - Street 2:SUITE 523
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5105
Mailing Address - Country:US
Mailing Address - Phone:818-905-3355
Mailing Address - Fax:818-905-0044
Practice Address - Street 1:14925 BURBANK BLVD.
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91411-2110
Practice Address - Country:US
Practice Address - Phone:818-905-3355
Practice Address - Fax:818-905-0044
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61974174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG59104Medicare UPIN
CAA61974Medicare ID - Type Unspecified