Healthcare Provider Details

I. General information

NPI: 1093128688
Provider Name (Legal Business Name): PEYMAN BANOONI MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 06/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6120 SEVILLE AVE UNIT B
HUNTINGTON PARK CA
90255-2911
US

IV. Provider business mailing address

269 S BEVERLY DR 468
BEVERLY HILLS CA
90212-3851
US

V. Phone/Fax

Practice location:
  • Phone: 323-588-8855
  • Fax: 323-587-5474
Mailing address:
  • Phone: 323-588-8855
  • Fax: 323-587-5474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA75080
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA75080
License Number StateCA

VIII. Authorized Official

Name: PEYMAN BANOONI
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 323-588-8855