Healthcare Provider Details

I. General information

NPI: 1588832059
Provider Name (Legal Business Name): MANIJEH KHAKPOUR NIKAKHTAR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2008
Last Update Date: 02/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 26TH ST
SANTA MONICA CA
90403-2203
US

IV. Provider business mailing address

927 26TH ST
SANTA MONICA CA
90403-2203
US

V. Phone/Fax

Practice location:
  • Phone: 310-344-0000
  • Fax:
Mailing address:
  • Phone: 310-344-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberA40053
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA40053
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberA40053
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA40053
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberA40053
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: