Provider Demographics
NPI:1861473464
Name:VAHEDIFAR, PAYAM (MD)
Entity Type:Individual
Prefix:DR
First Name:PAYAM
Middle Name:
Last Name:VAHEDIFAR
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 1:16311 VENTURA BLVD
Mailing Address - Street 2:SUITE 800
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2124
Mailing Address - Country:US
Mailing Address - Phone:818-788-7343
Mailing Address - Fax:818-788-9453
Practice Address - Street 1:16311 VENTURA BLVD
Practice Address - Street 2:SUITE 800
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2124
Practice Address - Country:US
Practice Address - Phone:818-788-7343
Practice Address - Fax:818-788-9453
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA636172081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A636170Medicaid
CAH32916Medicare UPIN
CA00A636170Medicaid