Provider Demographics
NPI:1942369715
Name:INSTITUTE OF DIAGNOSTIC MEDICINE
Entity Type:Organization
Organization Name:INSTITUTE OF DIAGNOSTIC MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:MR
Authorized Official - First Name:KHASHAYAR
Authorized Official - Middle Name:
Authorized Official - Last Name:POURMAND
Authorized Official - Suffix:
Authorized Official - Credentials:RNCST
Authorized Official - Phone:310-592-5067
Mailing Address - Street 1:6230 RESEDA BLVD APT 213
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-6930
Mailing Address - Country:US
Mailing Address - Phone:310-592-5067
Mailing Address - Fax:
Practice Address - Street 1:6230 RESEDA BLVD APT 213
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91335-6930
Practice Address - Country:US
Practice Address - Phone:310-592-5067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA704246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnosticGroup - Single Specialty