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General NPI Number Information
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NPI Number | 1912545062
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Entity Type | Individual
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Provider Name | MILAD GHASEMITABAR
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Gender | Male
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Dates
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Enumeration Date | 12/18/2019
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Last Update Date | 12/18/2019
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Provider Practice Location Address
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Address Line | 200 N ROBERTSON BLVD
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City | BEVERLY HILLS
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State | CA
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Zip | 90211-1769
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Country | US
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Telephone | 310-273-8256
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Fax |
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Provider Business Mailing Address
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Address Line | 14111 VANCE JACKSON RD APT 10207
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City | SAN ANTONIO
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State | TX
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Zip | 78249-2168
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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 | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | PT297677
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License Number State | CA
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