MEDICARE: ESRORULEH TAMIM MOHAMMAD PHD

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	103TC0700X	Clinical Psychologist	29114	CA

General Provider Information

NPI Number	:	1376773713
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ESRORULEH TAMIM MOHAMMAD PHD

Provider Business Mailing Address
First Line	:	4221 WILSHIRE BLVD STE 170-14
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-3519
Country	:	US
Telephone Number	:	510-921-9339
Fax Number	:

Provider Business Practice Location Address
First Line	:	4221 WILSHIRE BLVD STE 170-14
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-3519
Country	:	US
Telephone Number	:	510-921-9339
Fax Number	:

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

Provider Enumeration Date	:	07/20/2009
Last Update Date	:	03/06/2020

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