=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184021040
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOSHE S HENDIZADEH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2014
-----------------------------------------------------
Last Update Date | 05/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10966 W PICO BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90064-2115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-422-6111
-----------------------------------------------------
Fax | 310-861-9926
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10966 W PICO BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90064-2115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-422-6111
-----------------------------------------------------
Fax | 310-861-9926
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | A139684
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------