MEDICARE: KEVIN PEZESHKI MD INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	A67148	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184817496
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEVIN PEZESHKI MD INC

Provider Business Mailing Address
First Line	:	13750 VICTORY BLVD
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91401-2324
Country	:	US
Telephone Number	:	818-909-9955
Fax Number	:	818-909-0454

Provider Business Practice Location Address
First Line	:	13750 VICTORY BLVD
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91401-2324
Country	:	US
Telephone Number	:	818-909-9955
Fax Number	:	818-909-0454

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. KEVIN PEZESHKI
Credential	:	M.D.
Telephone Number	:	818-909-9955

Provider Enumeration Date	:	08/20/2007
Last Update Date	:	08/20/2007

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