Healthcare Provider Details

I. General information

NPI: 1366970832
Provider Name (Legal Business Name): MONTREH TAVAKKOLI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2017
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W HELLMAN AVE STE 303
MONTEREY PARK CA
91754-1209
US

IV. Provider business mailing address

120 W HELLMAN AVE STE 303
MONTEREY PARK CA
91754-1209
US

V. Phone/Fax

Practice location:
  • Phone: 310-400-0645
  • Fax: 424-270-6232
Mailing address:
  • Phone: 310-400-0645
  • Fax: 424-270-6232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA197460
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberA197460
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: