Healthcare Provider Details

I. General information

NPI: 1184192049
Provider Name (Legal Business Name): JAVID GHANDEHARI, MD, A CALIFORNIA MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2018
Last Update Date: 11/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1328 22ND ST
SANTA MONICA CA
90404-2032
US

IV. Provider business mailing address

150 W CIVIC CENTER DR STE 200
SANDY UT
84070-4284
US

V. Phone/Fax

Practice location:
  • Phone: 310-829-5511
  • Fax:
Mailing address:
  • Phone: 888-854-3822
  • Fax: 770-701-6673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JAVID GHANDEHARI
Title or Position: OWNER
Credential: MD
Phone: 210-845-6268