Provider Demographics
NPI:1255610739
Name:BEHROOZ AHMADI, M.D A PROF CORP
Entity type:Organization
Organization Name:BEHROOZ AHMADI, M.D A PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BEHROOZ
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMADI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-739-5816
Mailing Address - Street 1:5451 LA PALMA AVE
Mailing Address - Street 2:#34
Mailing Address - City:LA PALMA
Mailing Address - State:CA
Mailing Address - Zip Code:90623-1728
Mailing Address - Country:US
Mailing Address - Phone:714-739-5816
Mailing Address - Fax:714-739-2450
Practice Address - Street 1:5451 LA PALMA AVE
Practice Address - Street 2:#34
Practice Address - City:LA PALMA
Practice Address - State:CA
Practice Address - Zip Code:90623-1728
Practice Address - Country:US
Practice Address - Phone:714-739-5816
Practice Address - Fax:714-739-2450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA22029174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA22880Medicare UPIN
CAA22029AMedicare PIN