Basic Information
| Provider Information | |||||||||
| NPI: | 1467717975 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEHRAS AKHAVAN, MD, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | L.A. PAIN MEDICINE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4940 VAN NUYS BLVD | ||||||||
| Address2: | STE 301 | ||||||||
| City: | SHERMAN OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914031700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189909050 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4940 VAN NUYS BLVD | ||||||||
| Address2: | STE 301 | ||||||||
| City: | SHERMAN OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914031700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189909050 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2012 | ||||||||
| LastUpdateDate: | 07/10/2012 | ||||||||
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| AuthorizedOfficialLastName: | AKHAVAN | ||||||||
| AuthorizedOfficialFirstName: | MEHRAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8189909050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204R00000X | A82275 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Electrodiagnostic Medicine | 2081P2900X | A82275 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 208VP0014X | A82275 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 208100000X | A82275 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | A82275 | 01 | CA | LICENSE | OTHER |