MEDICARE: PEYMAN BANOONI MEDICAL GROUP 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	207V00000X	Obstetrics & Gynecology Physician
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1689978850
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEYMAN BANOONI MEDICAL GROUP INC

Provider Business Mailing Address
First Line	:	1919 W 7TH ST
Second Line	:	UNIT 2A
City	:	LOS ANGELES
State	:	CA
Zip	:	90057-4103
Country	:	US
Telephone Number	:	310-625-4643
Fax Number	:	310-652-3489

Provider Business Practice Location Address
First Line	:	1919 W 7TH ST
Second Line	:	UNIT 2A
City	:	LOS ANGELES
State	:	CA
Zip	:	90057-4103
Country	:	US
Telephone Number	:	310-625-4643
Fax Number	:	310-652-3489

Authorized Official
Title or Position	:	OWNER
Name	:	PEYMAN BANOONI
Credential	:	M.D.
Telephone Number	:	310-625-4643

Provider Enumeration Date	:	01/03/2011
Last Update Date	:	01/03/2011

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