Healthcare Provider Details

I. General information

NPI: 1316409584
Provider Name (Legal Business Name): YASAMIN NANAZ GHIASI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2019
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8641 WILSHIRE BLVD STE 210
BEVERLY HILLS CA
90211-2920
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-855-7002
  • Fax:
Mailing address:
  • Phone: 310-301-8707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberA177332
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207KI0005X
TaxonomyClinical & Laboratory Immunology (Allergy & Immunology) Physician
License NumberA177332
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberA177332
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: