Basic Information
| Provider Information | |||||||||
| NPI: | 1326243015 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAHYAR GANJIANPOUR DO A PROFESSIONAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 HOLLAND STE 101 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926182568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495882190 | ||||||||
| FaxNumber: | 9495882199 | ||||||||
| Practice Location | |||||||||
| Address1: | 16237 VENTURA BLVD | ||||||||
| Address2: | |||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914362201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495882190 | ||||||||
| FaxNumber: | 9495882199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2007 | ||||||||
| LastUpdateDate: | 10/17/2007 | ||||||||
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| AuthorizedOfficialLastName: | SIGMAN | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9495882190 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 20A8206 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00AX82060 | 05 | CA | MEDICAID |