Provider Demographics
NPI:1821652462
Name:DJAZAYERI, SAM (DO)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:
Last Name:DJAZAYERI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:SAM
Other - Middle Name:
Other - Last Name:JAZAYERI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:7289 DARNOCH WAY
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-1803
Mailing Address - Country:US
Mailing Address - Phone:818-912-1028
Mailing Address - Fax:
Practice Address - Street 1:147 N BRENT ST
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2809
Practice Address - Country:US
Practice Address - Phone:805-948-5672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A20057207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program