=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114933314
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ABDOLRASOOL EBRAHIMI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 575 E HARDY STREET SUITE 221
-----------------------------------------------------
City | INGLEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-677-9131
-----------------------------------------------------
Fax | 310-544-7262
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6390 CHARTRES DR
-----------------------------------------------------
City | RANCHO PALOS VERDES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-677-9131
-----------------------------------------------------
Fax | 310-677-0254
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | C405200
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------