Basic Information
| Provider Information | |||||||||
| NPI: | 1487686846 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANJIANPOUR | ||||||||
| FirstName: | MAHYAR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 HOLLAND | ||||||||
| Address2: | STE 101 | ||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926182568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495882190 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16237 VENTURA BLVD | ||||||||
| Address2: | |||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914362201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189955000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 05/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 20A8206 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | AX82060 | 05 | CA | MEDICAID |