Provider Demographics
NPI:1801113824
Name:STAR UROLOGY INCORPORATED
Entity type:Organization
Organization Name:STAR UROLOGY INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KAMAYAR
Authorized Official - Middle Name:
Authorized Official - Last Name:EBRAHIMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-246-3300
Mailing Address - Street 1:1577 E CHEVY CHASE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4192
Mailing Address - Country:US
Mailing Address - Phone:818-246-3300
Mailing Address - Fax:818-246-3305
Practice Address - Street 1:1577 E CHEVY CHASE DR STE 100
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4192
Practice Address - Country:US
Practice Address - Phone:818-246-3300
Practice Address - Fax:818-246-3305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-29
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91899208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADP069AMedicare PIN