Healthcare Provider Details

I. General information

NPI: 1134132798
Provider Name (Legal Business Name): JAMSHID NIKNAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 01/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 S LA BREA AVE STE 205
INGLEWOOD CA
90301-2321
US

IV. Provider business mailing address

401 S LA BREA AVE STE 205
INGLEWOOD CA
90301-2321
US

V. Phone/Fax

Practice location:
  • Phone: 310-275-7575
  • Fax: 310-424-3404
Mailing address:
  • Phone: 310-275-7575
  • Fax: 310-424-3404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA52081
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA52081
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: