Provider Demographics
NPI:1811949134
Name:JAVAHERIAN, OMID M (DC)
Entity type:Individual
Prefix:DR
First Name:OMID
Middle Name:M
Last Name:JAVAHERIAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12525 MAGNOLIA BLVD
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-2305
Mailing Address - Country:US
Mailing Address - Phone:818-760-4614
Mailing Address - Fax:818-760-2786
Practice Address - Street 1:12525 MAGNOLIA BLVD
Practice Address - Street 2:
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-2305
Practice Address - Country:US
Practice Address - Phone:818-760-4614
Practice Address - Fax:818-760-2786
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC23177111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU34987Medicare ID - Type Unspecified