Provider Demographics
NPI:1669644399
Name:ANSARI, AZITA
Entity type:Individual
Prefix:
First Name:AZITA
Middle Name:
Last Name:ANSARI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 MIDVALE AVE
Mailing Address - Street 2:202
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-6268
Mailing Address - Country:US
Mailing Address - Phone:310-365-3116
Mailing Address - Fax:
Practice Address - Street 1:2265 WESTWOOD BLVD STE A
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-2050
Practice Address - Country:US
Practice Address - Phone:310-365-3116
Practice Address - Fax:310-234-3401
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 7466171100000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No174400000XOther Service ProvidersSpecialist