MEDICARE: DR. MATTHEW ISAAC DERAKHSHESH MD

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	390200000X	Student in an Organized Health Care Education/Training Program	64149

General Provider Information

NPI Number	:	1700346566
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW ISAAC DERAKHSHESH MD

Provider Business Mailing Address
First Line	:	757 WESTWOOD PLZ
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-8358
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	757 WESTWOOD PLZ
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-3412
Country	:	US
Telephone Number	:	310-825-9111
Fax Number	:

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

Provider Enumeration Date	:	03/20/2019
Last Update Date	:	06/17/2025

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