Healthcare Provider Details

I. General information

NPI: 1346712866
Provider Name (Legal Business Name): SIMONA DAVOUDPOUR DO A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2018
Last Update Date: 12/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5757 WILSHIRE BLVD. PROMENADE 2
LOS ANGELES CA
90036
US

IV. Provider business mailing address

1270 S ALFRED ST UNIT 351614
LOS ANGELES CA
90035-8066
US

V. Phone/Fax

Practice location:
  • Phone: 424-284-9027
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SIMONA DAVOUDPOUR
Title or Position: PRESIDENT
Credential: DO
Phone: 424-284-9027