Healthcare Provider Details

I. General information

NPI: 1114916376
Provider Name (Legal Business Name): SAM A EBRAHIMI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: SAM AFKHAM-EBRAHIMI MD

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 10/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18375 VENTURA BLVD SUITE# 404
TARZANA CA
91356-4218
US

IV. Provider business mailing address

18375 VENTURA BLVD SUITE# 404
TARZANA CA
91356-4218
US

V. Phone/Fax

Practice location:
  • Phone: 818-422-5322
  • Fax:
Mailing address:
  • Phone: 301-537-7751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD33806
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number0101233742
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberD0059318
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberA060777
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: