Provider Demographics
NPI:1851496145
Name:DANESHVARI, SAM F (MD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:F
Last Name:DANESHVARI
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 1:1505 WILSON TER
Mailing Address - Street 2:SUITE #155
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4071
Mailing Address - Country:US
Mailing Address - Phone:818-500-4055
Mailing Address - Fax:818-500-4065
Practice Address - Street 1:1505 WILSON TER
Practice Address - Street 2:SUITE #155
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4071
Practice Address - Country:US
Practice Address - Phone:818-500-4055
Practice Address - Fax:818-500-4065
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA60891207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A608910Medicaid
H28964Medicare UPIN
CA00A608910Medicaid