Healthcare Provider Details

I. General information

NPI: 1952575342
Provider Name (Legal Business Name): SOM KOHANZADEH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2008
Last Update Date: 07/06/2020
Certification Date: 07/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 N ROBERTSON BLVD STE 106
BEVERLY HILLS CA
90211-1767
US

IV. Provider business mailing address

9663 SANTA MONICA BLVD # 1151
BEVERLY HILLS CA
90210-4303
US

V. Phone/Fax

Practice location:
  • Phone: 310-919-4179
  • Fax: 818-643-4255
Mailing address:
  • Phone: 310-919-4179
  • Fax: 818-643-4255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA95627
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberA95627
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: