=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124071972
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BAHRAM ALAVYNEJAD MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2006
-----------------------------------------------------
Last Update Date | 02/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 HOAG DR RADIOLOGY DEPTARTMENT
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92663-4162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-764-6876
-----------------------------------------------------
Fax | 949-764-6874
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 749226
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90074-9226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-263-8620
-----------------------------------------------------
Fax | 949-263-1639
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | A74844
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------