Healthcare Provider Details

I. General information

NPI: 1689978850
Provider Name (Legal Business Name): PEYMAN BANOONI MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2011
Last Update Date: 01/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 W 7TH ST UNIT 2A
LOS ANGELES CA
90057-4103
US

IV. Provider business mailing address

1919 W 7TH ST UNIT 2A
LOS ANGELES CA
90057-4103
US

V. Phone/Fax

Practice location:
  • Phone: 310-625-4643
  • Fax: 310-652-3489
Mailing address:
  • Phone: 310-625-4643
  • Fax: 310-652-3489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: PEYMAN BANOONI
Title or Position: OWNER
Credential: M.D.
Phone: 310-625-4643