Provider Demographics
NPI:1770816464
Name:MEHDIZADEH, OMID BENJAMIN
Entity Type:Individual
Prefix:
First Name:OMID
Middle Name:BENJAMIN
Last Name:MEHDIZADEH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 SANTA MONICA BLVD FL 3
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2023
Mailing Address - Country:US
Mailing Address - Phone:310-829-8868
Mailing Address - Fax:
Practice Address - Street 1:2125 ARIZONA AVE
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1337
Practice Address - Country:US
Practice Address - Phone:310-829-8701
Practice Address - Fax:310-315-4062
Is Sole Proprietor?:No
Enumeration Date:2009-09-12
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA150014207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology