=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861815771
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOHSEN KHERADPEZHOUH MD, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2014
-----------------------------------------------------
Last Update Date | 02/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10465 EASTBORNE AVE APT 306
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90024-6181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-248-0364
-----------------------------------------------------
Fax | 818-247-1330
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10465 EASTBORNE AVE APT 306
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90024-6181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-248-0364
-----------------------------------------------------
Fax | 818-247-1330
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MOHSEN KHERADPEZHOUH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-248-0364
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | A99424
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------