Healthcare Provider Details

I. General information

NPI: 1396877387
Provider Name (Legal Business Name): JENNIFER LYN MEHDIZADEH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5411 ETIWANDA AVE STE 200
TARZANA CA
91356-6160
US

IV. Provider business mailing address

PO BOX 54679
LOS ANGELES CA
90054-0679
US

V. Phone/Fax

Practice location:
  • Phone: 424-314-0125
  • Fax: 424-314-0128
Mailing address:
  • Phone: 424-314-0125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License NumberA85757
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberA85757
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: