Healthcare Provider Details

I. General information

NPI: 1922242569
Provider Name (Legal Business Name): STEPHANIE LUCINE PEZESHKIAN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE LUCINE KHANBABIAN D.O.

II. Dates (important events)

Enumeration Date: 04/27/2009
Last Update Date: 08/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5427 WHITTIER BLVD
LOS ANGELES CA
90022-4101
US

IV. Provider business mailing address

5427 WHITTIER BLVD
LOS ANGELES CA
90022-4101
US

V. Phone/Fax

Practice location:
  • Phone: 323-869-1900
  • Fax:
Mailing address:
  • Phone: 323-869-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A11487
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: