Basic Information
| Provider Information | |||||||||
| NPI: | 1104929082 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EBRAHIM HAZANY MD A MEDICAL CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COPE CLINIC INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 NEWBURY RD STE 240 | ||||||||
| Address2: | |||||||||
| City: | NEWBURY PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913206443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054981400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1000 NEWBURY RD STE 240 | ||||||||
| Address2: | |||||||||
| City: | NEWBURY PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913206443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054981400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAZANY | ||||||||
| AuthorizedOfficialFirstName: | EBRAHIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8054981400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | A53409 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.