Provider Demographics
NPI:1922371228
Name:SAMIR B. DAMANI MD INC
Entity Type:Organization
Organization Name:SAMIR B. DAMANI MD INC
Other - Org Name:MD REVOLUTION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:B
Authorized Official - Last Name:DAMANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-847-5064
Mailing Address - Street 1:9850 GENESEE AVE
Mailing Address - Street 2:SUITE 730
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:858-847-5064
Mailing Address - Fax:858-433-4099
Practice Address - Street 1:9850 GENESEE AVE
Practice Address - Street 2:SUITE 730
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037
Practice Address - Country:US
Practice Address - Phone:858-847-5064
Practice Address - Fax:858-433-4099
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MD REVOLUTION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-02-16
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 207RC0000X, 207SG0201X
CAA88989207R00000X, 207RC0000X, 207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A889890Medicaid
CA00A889890Medicaid
CA159583Medicare UPIN