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General NPI Number Information
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NPI Number | 1720322415
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Entity Type | Organization
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Legal Business Name | BRENTWOOD MEDICAL GROUP A PROFESSIONAL MEDICAL CORP
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Dates
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Enumeration Date | 11/19/2012
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Last Update Date | 02/26/2018
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Provider Practice Location Address
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Address Line | 11645 WILSHIRE BLVD SUITE 745
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City | LOS ANGELES
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State | CA
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Zip | 90025-1708
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Country | US
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Telephone | 310-696-0101
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Fax |
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Provider Business Mailing Address
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Address Line | 11645 WILSHIRE BLVD SUITE 745
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City | LOS ANGELES
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State | CA
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Zip | 90025-1708
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Country | US
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Telephone | 310-696-0101
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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. JAVID TAVARI
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Credential | D.O.
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Telephone | 310-696-0101
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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 | 20A6273
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License Number State | CA
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