Provider Demographics
NPI:1356438204
Name:L A SURGERY-COLORECTAL SURGERY INC
Entity type:Organization
Organization Name:L A SURGERY-COLORECTAL SURGERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:A
Authorized Official - Last Name:POURSHAHMIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-205-3540
Mailing Address - Street 1:4400 W RIVERSIDE DR STE 110-2780
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4046
Mailing Address - Country:US
Mailing Address - Phone:818-205-3540
Mailing Address - Fax:818-783-9607
Practice Address - Street 1:5353 BALBOA BLVD STE 201
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-2865
Practice Address - Country:US
Practice Address - Phone:818-783-7277
Practice Address - Fax:818-783-9607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78449208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH85348Medicare UPIN