=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063078764
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRYAN DANIEL KIMIABAKHSH MD, MS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2019
-----------------------------------------------------
Last Update Date | 01/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2021 SANTA MONICA BLVD STE 625E
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90404-2169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-829-8948
-----------------------------------------------------
Fax | 424-212-5937
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38 HEMLOCK DRIVE
-----------------------------------------------------
City | GREAT NECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-984-9199
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | A196784
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------