=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417238205
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEPEHR LALEZARI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2011
-----------------------------------------------------
Last Update Date | 03/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1245 WILSHIRE BLVD STE 907
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90017-4809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-545-1656
-----------------------------------------------------
Fax | 213-606-0586
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 606 S HILL ST STE 218
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-545-1656
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | D80875
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 141683
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------