Provider Demographics
NPI:1720068448
Name:KERMANI, TANAZ A (MD)
Entity Type:Individual
Prefix:
First Name:TANAZ
Middle Name:A
Last Name:KERMANI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 540
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2023
Mailing Address - Country:US
Mailing Address - Phone:310-582-6350
Mailing Address - Fax:310-582-6352
Practice Address - Street 1:2020 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 540
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2023
Practice Address - Country:US
Practice Address - Phone:310-582-6350
Practice Address - Fax:310-582-6352
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47693207RR0500X
CAA118919207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1720068448OtherCCS PANELED
CA1720068448Medicaid
MN143411000Medicaid
P00388219Medicare ID - Type UnspecifiedRAILROAD
MN143411000Medicaid
CAFX415ZMedicare PIN
I36045Medicare UPIN