Healthcare Provider Details

I. General information

NPI: 1629265434
Provider Name (Legal Business Name): KHODAMRAD PAYMAN, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2007
Last Update Date: 01/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17525 VENTURA BLVD SUITE 203
ENCINO CA
91316-3843
US

IV. Provider business mailing address

17525 VENTURA BLVD SUITE 203
ENCINO CA
91316-3843
US

V. Phone/Fax

Practice location:
  • Phone: 818-986-0200
  • Fax: 818-986-4393
Mailing address:
  • Phone: 818-986-0200
  • Fax: 818-986-4393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberA75190
License Number StateCA

VIII. Authorized Official

Name: DR. KHODAM-RAD PAYMAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 310-428-6667