Healthcare Provider Details

I. General information

NPI: 1861633166
Provider Name (Legal Business Name): FARZAD DAVID MAHJOUBI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2009
Last Update Date: 01/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14850 ROSCOE BLVD
PANORAMA CA
91402-4618
US

IV. Provider business mailing address

PO BOX 5486
ORANGE CA
92863-5486
US

V. Phone/Fax

Practice location:
  • Phone: 818-787-2222
  • Fax:
Mailing address:
  • Phone: 818-550-0900
  • Fax: 505-293-1524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA97383
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: