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General NPI Number Information
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NPI Number | 1013475805
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Entity Type | Organization
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Legal Business Name | AK DERM CORP
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Dates
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Enumeration Date | 03/11/2019
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Last Update Date | 03/11/2019
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Provider Practice Location Address
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Address Line | 16030 VENTURA BLVD STE 100
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City | ENCINO
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State | CA
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Zip | 91436-2754
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Country | US
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Telephone | 949-412-6011
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Fax |
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Provider Business Mailing Address
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Address Line | 15526 AQUA VERDE DR
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City | LOS ANGELES
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State | CA
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Zip | 90077-1504
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. AVA KHOSRAVIANI
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Credential | MD
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Telephone | 949-412-6011
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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