Healthcare Provider Details

I. General information

NPI: 1992840680
Provider Name (Legal Business Name): JAVID TAVARI, D.O., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 10/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11645 WILSHIRE BLVD SUITE 745
LOS ANGELES CA
90025-1708
US

IV. Provider business mailing address

11645 WILSHIRE BLVD SUITE 745
LOS ANGELES CA
90025-1708
US

V. Phone/Fax

Practice location:
  • Phone: 310-696-0100
  • Fax: 310-696-0700
Mailing address:
  • Phone: 310-696-0100
  • Fax: 310-696-0700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A6273
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number20A6273
License Number StateCA

VIII. Authorized Official

Name: DR. JAVID D TAVARI
Title or Position: CEO
Credential: D.O.
Phone: 310-696-0100