Healthcare Provider Details

I. General information

NPI: 1861473464
Provider Name (Legal Business Name): PAYAM VAHEDIFAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16311 VENTURA BLVD SUITE 800
ENCINO CA
91436-2124
US

IV. Provider business mailing address

16311 VENTURA BLVD SUITE 800
ENCINO CA
91436-2124
US

V. Phone/Fax

Practice location:
  • Phone: 818-788-7343
  • Fax: 818-788-9453
Mailing address:
  • Phone: 818-788-7343
  • Fax: 818-788-9453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA63617
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: