Healthcare Provider Details

I. General information

NPI: 1669400602
Provider Name (Legal Business Name): JAVID D TAVARI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 10/25/2011
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 TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A6273
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: