Healthcare Provider Details

I. General information

NPI: 1710073390
Provider Name (Legal Business Name): ST. JOHN'S URGENT CARE & MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 04/01/2020
Certification Date: 04/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1119 N WESTERN AVE STE G
LOS ANGELES CA
90029-1070
US

IV. Provider business mailing address

1119 N WESTERN AVE STE G
LOS ANGELES CA
90029-1070
US

V. Phone/Fax

Practice location:
  • Phone: 323-957-9300
  • Fax: 323-957-9315
Mailing address:
  • Phone: 323-957-9300
  • Fax: 323-957-9315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MIKE M ROSTAMI SR.
Title or Position: PHYSICIAN/CEO
Credential: M.D
Phone: 323-957-9300