Provider Demographics
NPI:1740349851
Name:KASHANI, ATA M (MD)
Entity type:Individual
Prefix:
First Name:ATA
Middle Name:M
Last Name:KASHANI
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 1:18355 SHERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-4436
Mailing Address - Country:US
Mailing Address - Phone:818-343-0964
Mailing Address - Fax:818-343-0768
Practice Address - Street 1:18355 SHERMAN WAY
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-4436
Practice Address - Country:US
Practice Address - Phone:818-343-0964
Practice Address - Fax:818-343-0768
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41464207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A414640Medicaid
A41464Medicare ID - Type Unspecified
CA1086117Medicare UPIN