Healthcare Provider Details

I. General information

NPI: 1326452905
Provider Name (Legal Business Name): FATANEH AMIDI MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 06/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 LOMITA BLVD SUITE 500
TORRANCE CA
90505-4909
US

IV. Provider business mailing address

PO BOX 3129
TORRANCE CA
90510-3129
US

V. Phone/Fax

Practice location:
  • Phone: 310-373-7900
  • Fax: 310-373-7940
Mailing address:
  • Phone: 310-792-3914
  • Fax: 855-898-4055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA118879
License Number StateCA

VIII. Authorized Official

Name: DR. FATANEH AMIDI
Title or Position: PRESIDENT
Credential: M.D,
Phone: 310-373-7900