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General NPI Number Information
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NPI Number | 1366717746
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Entity Type | Organization
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Legal Business Name | SEPEHR KHONSARI - A MEDICAL CORP
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Dates
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Enumeration Date | 03/19/2012
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Last Update Date | 03/19/2012
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Provider Practice Location Address
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Address Line | 2260 HOMET RD
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City | SAN MARINO
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State | CA
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Zip | 91108-1326
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Country | US
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Telephone | 949-334-7374
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Fax |
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Provider Business Mailing Address
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Address Line | 2260 HOMET RD
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City | SAN MARINO
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State | CA
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Zip | 91108-1326
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Country | US
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Telephone | 949-334-7374
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SEPEHR KHONSARI
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Credential | M.D,
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Telephone | 949-334-7374
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | A85324
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License Number State | CA
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