Provider Demographics
NPI:1952568305
Name:PAYAM DANESHRAD MD INC
Entity Type:Organization
Organization Name:PAYAM DANESHRAD MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-453-6500
Mailing Address - Street 1:1301 20TH ST
Mailing Address - Street 2:470
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2050
Mailing Address - Country:US
Mailing Address - Phone:310-453-6500
Mailing Address - Fax:310-453-6681
Practice Address - Street 1:1301 20TH ST
Practice Address - Street 2:470
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2050
Practice Address - Country:US
Practice Address - Phone:310-453-6500
Practice Address - Fax:310-453-6681
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PAYAM DANESHRAD MD INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-21
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71327207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH59894Medicare UPIN
CAA71327Medicare Oscar/Certification