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General NPI Number Information
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NPI Number | 1508429143
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Entity Type | Individual
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Provider Name | MASTANEH NIKRAVESH MD
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Gender | Female
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Dates
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Enumeration Date | 04/18/2019
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Last Update Date | 03/11/2025
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Provider Practice Location Address
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Address Line | 5555 GROSSMONT CENTER DR
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City | LA MESA
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State | CA
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Zip | 91942-3019
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Country | US
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Telephone | 619-740-6000
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Fax |
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Provider Business Mailing Address
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Address Line | 600 1ST AVE STE 102-2405
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City | SEATTLE
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State | WA
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Zip | 98104-2210
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | A176795
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 2083A0300X
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Taxonomy Name | Addiction Medicine (Preventive Medicine) Physician
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License Number | A176795
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number | A176795
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License Number State | CA
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