Healthcare Provider Details

I. General information

NPI: 1083969018
Provider Name (Legal Business Name): P.B. NIKRAVESH DPM, APC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2012
Last Update Date: 07/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6404 WILSHIRE BLVD STE 600
LOS ANGELES CA
90048-5501
US

IV. Provider business mailing address

6404 WILSHIRE BLVD STE 600
LOS ANGELES CA
90048-5501
US

V. Phone/Fax

Practice location:
  • Phone: 323-782-8586
  • Fax: 323-782-8528
Mailing address:
  • Phone: 323-782-8586
  • Fax: 323-782-8528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberE4103
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE4103
License Number StateCA

VIII. Authorized Official

Name: YVETTE URETA
Title or Position: MEDICAL ASSISTANT
Credential:
Phone: 323-782-8586