MEDICARE: ALI GHEISSARI M.D.

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	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	G72926	CA

General Provider Information

NPI Number	:	1376545269
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALI GHEISSARI M.D.

Provider Business Mailing Address
First Line	:	1245 WILSHIRE BLVD
Second Line	:	SUITE 606
City	:	LOS ANGELES
State	:	CA
Zip	:	90017-4810
Country	:	US
Telephone Number	:	213-483-1055
Fax Number	:	213-483-1418

Provider Business Practice Location Address
First Line	:	1245 WILSHIRE BLVD
Second Line	:	SUITE 606
City	:	LOS ANGELES
State	:	CA
Zip	:	90017-4810
Country	:	US
Telephone Number	:	213-483-1055
Fax Number	:	213-483-1418

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	02/10/2020

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