Healthcare Provider Details

I. General information

NPI: 1447229570
Provider Name (Legal Business Name): MARK GANJIANPOUR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 01/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 SAN VICENTE BLVD SUITE 310
LOS ANGELES CA
90048-5425
US

IV. Provider business mailing address

6330 SAN VICENTE BLVD SUITE 310
LOS ANGELES CA
90048-5425
US

V. Phone/Fax

Practice location:
  • Phone: 310-855-0751
  • Fax: 310-358-2453
Mailing address:
  • Phone: 310-855-0751
  • Fax: 310-358-2453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberA71208
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: