Healthcare Provider Details

I. General information

NPI: 1851496145
Provider Name (Legal Business Name): SAM F DANESHVARI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 09/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 WILSON TER SUITE #155
GLENDALE CA
91206-4071
US

IV. Provider business mailing address

1505 WILSON TER SUITE #155
GLENDALE CA
91206-4071
US

V. Phone/Fax

Practice location:
  • Phone: 818-500-4055
  • Fax: 818-500-4065
Mailing address:
  • Phone: 818-500-4055
  • Fax: 818-500-4065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA60891
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: