=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104929777
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL KERMANI, MD, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2006
-----------------------------------------------------
Last Update Date | 01/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1441 AVOCADO AVE SUITE 501
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-7721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-640-2010
-----------------------------------------------------
Fax | 949-640-2090
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P O BOX 10711
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-640-2010
-----------------------------------------------------
Fax | 949-640-2090
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MICHAEL KERMANI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 949-640-2010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | A75009
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------