Provider Demographics
NPI:1154342269
Name:SAJEDI, EBRAHIM (MD)
Entity type:Individual
Prefix:
First Name:EBRAHIM
Middle Name:
Last Name:SAJEDI
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 1889
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-7889
Mailing Address - Country:US
Mailing Address - Phone:323-720-9204
Mailing Address - Fax:323-720-9208
Practice Address - Street 1:120 S MONTEBELLO BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4730
Practice Address - Country:US
Practice Address - Phone:323-726-0533
Practice Address - Fax:323-726-0274
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62264207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A622640Medicaid
CAG73414Medicare UPIN
CA00A622640Medicaid