Provider Demographics
NPI:1891789798
Name:SOOFER, BEHROOZ DAVID (DPM)
Entity Type:Individual
Prefix:
First Name:BEHROOZ
Middle Name:DAVID
Last Name:SOOFER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:BEHROOZ
Other - Middle Name:D
Other - Last Name:SOOFER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:10379 EASTBORNE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-5364
Mailing Address - Country:US
Mailing Address - Phone:310-430-8870
Mailing Address - Fax:323-432-0860
Practice Address - Street 1:10379 EASTBORNE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-5364
Practice Address - Country:US
Practice Address - Phone:310-430-8870
Practice Address - Fax:323-432-0860
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2023-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4059213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E40591OtherBLUESHIELD
CAE4059OtherBLUE CROSS
E4059OtherLICENSE NUMBER
CA000E40592Medicaid
CA480031462OtherMEDICARE RAILROAD
CA000E40592Medicaid
U69070Medicare UPIN
CA4621730003Medicare NSC