Provider Demographics
NPI:1750440681
Name:BEHROOZAN, BENJAMIN (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:BEHROOZAN
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 1:2221 LINCOLN BLVD # 200
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-1320
Mailing Address - Country:US
Mailing Address - Phone:310-396-9999
Mailing Address - Fax:310-664-8901
Practice Address - Street 1:2221 LINCOLN BLVD # 200
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-1320
Practice Address - Country:US
Practice Address - Phone:310-396-9999
Practice Address - Fax:310-664-8901
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41374207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A413741Medicaid
CAE98966Medicare UPIN
CAW10352AMedicare ID - Type Unspecified