Healthcare Provider Details

I. General information

NPI: 1750920153
Provider Name (Legal Business Name): SOORENA FATEHCHEHR MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2020
Last Update Date: 01/02/2020
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

529 E 10TH ST FL 2
LONG BEACH CA
90813-4508
US

IV. Provider business mailing address

4250 GLENCOE AVE UNIT 1114
MARINA DEL REY CA
90292-5660
US

V. Phone/Fax

Practice location:
  • Phone: 562-491-9047
  • Fax: 562-491-9251
Mailing address:
  • Phone: 310-869-3212
  • Fax: 949-502-8887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SOORENA FATEHCHEHR
Title or Position: CEO
Credential: MD
Phone: 310-869-3212