Provider Demographics
NPI:1134229966
Name:SHENASSA, BEHNAM BEN (MD)
Entity type:Individual
Prefix:
First Name:BEHNAM
Middle Name:BEN
Last Name:SHENASSA
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:PO BOX 4186
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91222-0186
Mailing Address - Country:US
Mailing Address - Phone:323-543-4250
Mailing Address - Fax:323-543-4255
Practice Address - Street 1:2750 W BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-1050
Practice Address - Country:US
Practice Address - Phone:818-241-3125
Practice Address - Fax:818-241-1652
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76062208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A760620Medicaid
CA00A760620Medicaid
CAA76062Medicare ID - Type Unspecified