Provider Demographics
NPI:1811143605
Name:SERVATJOO, PARVIZ PARIS
Entity type:Individual
Prefix:MR
First Name:PARVIZ
Middle Name:PARIS
Last Name:SERVATJOO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:PARVIZ
Other - Middle Name:PARIS
Other - Last Name:SERVATJOO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:7217 CANBY AVE
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-3003
Mailing Address - Country:US
Mailing Address - Phone:818-995-4040
Mailing Address - Fax:818-996-3219
Practice Address - Street 1:7217 CANBY AVE
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-3003
Practice Address - Country:US
Practice Address - Phone:818-995-4040
Practice Address - Fax:818-996-3219
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-12
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3494213ES0103X
247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWE3494BMedicare PIN