Healthcare Provider Details

I. General information

NPI: 1205126224
Provider Name (Legal Business Name): HOOSHANG TABIBIAN MEDICAL CORPORATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2011
Last Update Date: 02/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11611 SAN VICENTE BLVD GROUND FLOOR
LOS ANGELES CA
90049-5106
US

IV. Provider business mailing address

11611 SAN VICENTE BLVD GROUND FLOOR
LOS ANGELES CA
90049-5106
US

V. Phone/Fax

Practice location:
  • Phone: 310-447-6060
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberA40845
License Number StateCA

VIII. Authorized Official

Name: HOOSHANG TABIBIAN
Title or Position: OWNER
Credential: M.D.
Phone: 310-447-6060