Provider Demographics
NPI:1760544639
Name:DANIEL BEHROOZAN MD INC
Entity Type:Organization
Organization Name:DANIEL BEHROOZAN MD INC
Other - Org Name:DERMATOLOGY INSTITUTE OF SOUTHERN CALIFORNIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BEHROOZAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-392-1111
Mailing Address - Street 1:2221 LINCOLN BLVD
Mailing Address - Street 2:#100
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-1320
Mailing Address - Country:US
Mailing Address - Phone:310-392-1111
Mailing Address - Fax:
Practice Address - Street 1:2221 LINCOLN BLVD
Practice Address - Street 2:#100
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-1320
Practice Address - Country:US
Practice Address - Phone:310-392-1111
Practice Address - Fax:310-392-1101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76756207N00000X, 207ND0101X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW20251OtherMEDICARE GROUP ID
I13153Medicare UPIN