Provider Demographics
NPI:1891092797
Name:CALIFORNIA INSTITUTE FOR CARDIOVASCULAR AND LASER VEIN SURG
Entity Type:Organization
Organization Name:CALIFORNIA INSTITUTE FOR CARDIOVASCULAR AND LASER VEIN SURG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:EBRAHIMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-422-5322
Mailing Address - Street 1:18375 VENTURA BLVD # 404
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-4218
Mailing Address - Country:US
Mailing Address - Phone:818-422-5322
Mailing Address - Fax:818-578-8476
Practice Address - Street 1:16030 VENTURA BLVD STE 605
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-4471
Practice Address - Country:US
Practice Address - Phone:818-422-5322
Practice Address - Fax:818-578-8476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-12
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA060777208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD404465702Medicaid
DC035556900Medicaid
DC035556900Medicaid
DC019631W58Medicare PIN
MDH78581Medicare UPIN
CAEV886AMedicare UPIN