Healthcare Provider Details

I. General information

NPI: 1578394789
Provider Name (Legal Business Name): RONICA SARA MEHDIZADEH PA
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9400 BRIGHTON WAY STE 210
BEVERLY HILLS CA
90210-4709
US

IV. Provider business mailing address

9400 BRIGHTON WAY STE 210
BEVERLY HILLS CA
90210-4709
US

V. Phone/Fax

Practice location:
  • Phone: 310-362-1255
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA66107
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: