Healthcare Provider Details

I. General information

NPI: 1437192200
Provider Name (Legal Business Name): PAYAM BENJAMIN NIKRAVESH DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6404 WILSHIRE BLVD SUITE 600
LOS ANGELES CA
90048-5501
US

IV. Provider business mailing address

6404 WILSHIRE BLVD SUITE 600
LOS ANGELES CA
90048-5501
US

V. Phone/Fax

Practice location:
  • Phone: 323-782-8586
  • Fax: 323-782-8528
Mailing address:
  • Phone: 323-782-8586
  • Fax: 323-782-8528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE4103
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: