=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013065812
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEVITLANA SAFAEI MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2007
-----------------------------------------------------
Last Update Date | 02/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 520 SUPERIOR AVE STE 205
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92663-3637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-650-2462
-----------------------------------------------------
Fax | 949-650-1366
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3699
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92659-8699
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 657-241-3600
-----------------------------------------------------
Fax | 657-241-7708
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | A81174
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------