Healthcare Provider Details

I. General information

NPI: 1770993347
Provider Name (Legal Business Name): MEHDI F DERAMBKHSH MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2014
Last Update Date: 05/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 S BRISTOL ST SUITE 203
SANTA ANA CA
92704-7319
US

IV. Provider business mailing address

PO BOX 2474
PALOS VERDES PENINSULA CA
90274-8474
US

V. Phone/Fax

Practice location:
  • Phone: 714-542-3439
  • Fax: 888-505-0789
Mailing address:
  • Phone: 714-542-3439
  • Fax: 888-505-0789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA88950
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA88950
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA88950
License Number StateCA

VIII. Authorized Official

Name: DR. MEHDI FARSHAD DERAMBAKHSH
Title or Position: PRESIDENT/OWNER
Credential: M.D
Phone: 310-218-6415