Healthcare Provider Details

I. General information

NPI: 1164426953
Provider Name (Legal Business Name): AMIRHASSAN BAHREMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 10/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8851 CENTER DR SUITE 608
LA MESA CA
91942-3017
US

IV. Provider business mailing address

8851 CENTER DR SUITE 608
LA MESA CA
91942-3017
US

V. Phone/Fax

Practice location:
  • Phone: 619-460-5850
  • Fax: 619-460-5849
Mailing address:
  • Phone: 619-460-5850
  • Fax: 619-460-5849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number01059340A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: