Healthcare Provider Details

I. General information

NPI: 1891081253
Provider Name (Legal Business Name): SOORENA FATEHCHEHR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2011
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: 562-491-9047
  • Fax: 562-491-9251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberA132575
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: