Healthcare Provider Details

I. General information

NPI: 1811315641
Provider Name (Legal Business Name): ALEXANDER GHASEM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2014
Last Update Date: 04/26/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14860 ROSCOE BLVD STE 200
PANORAMA CITY CA
91402-4683
US

IV. Provider business mailing address

8447 WILSHIRE BLVD STE 202
BEVERLY HILLS CA
90211-3207
US

V. Phone/Fax

Practice location:
  • Phone: 424-201-5454
  • Fax:
Mailing address:
  • Phone: 424-201-5454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number82428
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberA169674
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: