Healthcare Provider Details

I. General information

NPI: 1902844525
Provider Name (Legal Business Name): HOSSEIN GHARAKHANI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 07/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2975 SYCAMORE DR EMERGENCY DEPARTMENT
SIMI VALLEY CA
93065-1201
US

IV. Provider business mailing address

4551 GLENCOE AVE SUITE 260
MARINA DEL REY CA
90292-6385
US

V. Phone/Fax

Practice location:
  • Phone: 805-955-6101
  • Fax:
Mailing address:
  • Phone: 310-301-2030
  • Fax: 310-306-5247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number20A7070
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: