Healthcare Provider Details

I. General information

NPI: 1346341575
Provider Name (Legal Business Name): PAYMON BANAFSHE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 05/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6222 W MANCHESTER AVE STE A
LOS ANGELES CA
90045-3801
US

IV. Provider business mailing address

6222 W MANCHESTER AVE STE A
LOS ANGELES CA
90045-3801
US

V. Phone/Fax

Practice location:
  • Phone: 310-670-1840
  • Fax: 310-670-4016
Mailing address:
  • Phone: 310-670-1840
  • Fax: 310-670-4016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number20A8510
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: