Healthcare Provider Details

I. General information

NPI: 1649282278
Provider Name (Legal Business Name): SIMON BOOSTANFAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 LA VENTA RD STE 209
WESTLAKE VILLAGE CA
91361-3767
US

IV. Provider business mailing address

1250 LA VENTA RD STE 209
WESTLAKE VILLAGE CA
91361-3767
US

V. Phone/Fax

Practice location:
  • Phone: 805-497-1649
  • Fax: 805-497-1069
Mailing address:
  • Phone: 805-497-1649
  • Fax: 805-497-1069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberA031384
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: