Provider Demographics
NPI:1720135726
Name:ROSTAMI, MIKE MANSOUR (MD)
Entity Type:Individual
Prefix:DR
First Name:MIKE
Middle Name:MANSOUR
Last Name:ROSTAMI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 N RODEO DR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-3209
Mailing Address - Country:US
Mailing Address - Phone:323-957-9300
Mailing Address - Fax:323-957-9315
Practice Address - Street 1:1119 N WESTERN AVE STE G
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-1070
Practice Address - Country:US
Practice Address - Phone:323-957-9300
Practice Address - Fax:323-957-9315
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50108208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15888Medicare PIN
CAF42632Medicare ID - Type Unspecified