Healthcare Provider Details

I. General information

NPI: 1912439894
Provider Name (Legal Business Name): CALIFORNIA CEREBROVASCULAR INSTITUTE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 03/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 LYNN RD SUITE 120
THOUSAND OAKS CA
91360-1935
US

IV. Provider business mailing address

3435 E THOUSAND OAKS BLVD SUITE 7735
WESTLAKE VILLAGE CA
91359-7901
US

V. Phone/Fax

Practice location:
  • Phone: 805-795-7656
  • Fax: 805-494-8621
Mailing address:
  • Phone: 805-795-7656
  • Fax: 805-494-8621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberA112672
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberA118331
License Number StateCA

VIII. Authorized Official

Name: MARTIN M MORTAZAVI
Title or Position: PARTNER
Credential: M.D.
Phone: 805-795-7656