Healthcare Provider Details

I. General information

NPI: 1528154192
Provider Name (Legal Business Name): BABAK K. DARVISH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 03/15/2014
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

11301 WILSHIRE BLVD DEPT. OF PM&R, MAIL CODE #117
LOS ANGELES CA
90073-1003
US

V. Phone/Fax

Practice location:
  • Phone: 818-225-5362
  • Fax:
Mailing address:
  • Phone: 310-478-3711
  • Fax: 310-268-4995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberA65838
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA65838
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA65838
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: