Healthcare Provider Details

I. General information

NPI: 1134744626
Provider Name (Legal Business Name): BORNA VAJDI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2020
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10250 SANTA MONICA BLVD STE 2440
LOS ANGELES CA
90067-6593
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-286-0122
  • Fax: 310-286-0125
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA184399
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: