Provider Demographics
NPI:1205126224
Name:HOOSHANG TABIBIAN MEDICAL CORPORATION, INC.
Entity type:Organization
Organization Name:HOOSHANG TABIBIAN MEDICAL CORPORATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HOOSHANG
Authorized Official - Middle Name:
Authorized Official - Last Name:TABIBIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-447-6060
Mailing Address - Street 1:11611 SAN VICENTE BLVD
Mailing Address - Street 2:GROUND FLOOR
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11611 SAN VICENTE BLVD
Practice Address - Street 2:GROUND FLOOR
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-5106
Practice Address - Country:US
Practice Address - Phone:310-447-6060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-11
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40845173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty