Healthcare Provider Details

I. General information

NPI: 1902069404
Provider Name (Legal Business Name): MASOUD VAZIRNEZAMI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 04/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4130 LA JOLLA VILLAGE DR STE 208
LA JOLLA CA
92037-9121
US

IV. Provider business mailing address

4130 LA JOLLA VILLAGE DR STE 107
LA JOLLA CA
92037-8402
US

V. Phone/Fax

Practice location:
  • Phone: 858-678-0081
  • Fax: 858-678-8580
Mailing address:
  • Phone: 619-734-8877
  • Fax: 978-313-6824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberAU2716
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: