Healthcare Provider Details

I. General information

NPI: 1538747050
Provider Name (Legal Business Name): MOHAMMAD ISMAIL EHSANI-NIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 LYNN RD
THOUSAND OAKS CA
91360-1935
US

IV. Provider business mailing address

2100 LYNN RD
THOUSAND OAKS CA
91360-1935
US

V. Phone/Fax

Practice location:
  • Phone: 805-497-4500
  • Fax:
Mailing address:
  • Phone: 805-497-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number25029
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: