Healthcare Provider Details

I. General information

NPI: 1457764276
Provider Name (Legal Business Name): SOM K PLASTIC SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2014
Last Update Date: 04/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8635 W 3RD ST SUITE 880W
LOS ANGELES CA
90048-6101
US

IV. Provider business mailing address

8635 W 3RD ST SUITE 880W
LOS ANGELES CA
90048-6101
US

V. Phone/Fax

Practice location:
  • Phone: 424-239-9743
  • Fax:
Mailing address:
  • Phone: 424-239-9743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA95627
License Number StateCA

VIII. Authorized Official

Name: DR. SOM KOHANZADEH
Title or Position: PRESIDENT
Credential: MD
Phone: 424-239-9743