Healthcare Provider Details

I. General information

NPI: 1336391473
Provider Name (Legal Business Name): SASSAN ROSTAMIPOUR SHIROYEH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 10/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 MCCONNELL AVE
LOS ANGELES CA
90066-7026
US

IV. Provider business mailing address

5300 MCCONNELL AVE
LOS ANGELES CA
90066-7026
US

V. Phone/Fax

Practice location:
  • Phone: 310-482-5331
  • Fax:
Mailing address:
  • Phone: 310-482-5331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License NumberA85114
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: