Provider Demographics
NPI:1760533426
Name:BEN B. SHENASSA, M.D. INC.
Entity Type:Organization
Organization Name:BEN B. SHENASSA, M.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INCORPORATOR
Authorized Official - Prefix:
Authorized Official - First Name:BEHNAM
Authorized Official - Middle Name:BEN
Authorized Official - Last Name:SHENASSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-543-4250
Mailing Address - Street 1:2750 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EAGLE ROCK
Mailing Address - State:CA
Mailing Address - Zip Code:90041-1050
Mailing Address - Country:US
Mailing Address - Phone:323-543-4250
Mailing Address - Fax:323-543-4255
Practice Address - Street 1:2750 W BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-1050
Practice Address - Country:US
Practice Address - Phone:323-543-4250
Practice Address - Fax:323-543-4255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76062174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG83677Medicare UPIN