Provider Demographics
NPI:1669946349
Name:BEHIKEESH, ROSTAM (MD(IR), LAC)
Entity type:Individual
Prefix:
First Name:ROSTAM
Middle Name:
Last Name:BEHIKEESH
Suffix:
Gender:M
Credentials:MD(IR), LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4111 TERRAZA DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-1040
Mailing Address - Country:US
Mailing Address - Phone:310-703-3419
Mailing Address - Fax:
Practice Address - Street 1:1807 WILSHIRE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5795
Practice Address - Country:US
Practice Address - Phone:310-703-3419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-16
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18355171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA83-3756085Medicaid