Healthcare Provider Details

I. General information

NPI: 1710549878
Provider Name (Legal Business Name): RASAM HAJIANNASAB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2019
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20001 S RANCHO WAY
RANCHO DOMINGUEZ CA
90220-6318
US

IV. Provider business mailing address

12902 USF MAGNOLIA DR
TAMPA FL
33612-9416
US

V. Phone/Fax

Practice location:
  • Phone: 310-225-3221
  • Fax: 310-698-7040
Mailing address:
  • Phone: 813-745-4673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberA193348
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: