Basic Information
| Provider Information | |||||||||
| NPI: | 1740236728 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ORTHOPEDIC PAIN MANAGEMENT CENTER, A MEDICAL CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JOINT SPINE & SPORT ORTHOPEDIC PAIN MANAGEMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16952 VENTURA BLVD | ||||||||
| Address2: | |||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913164197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187893964 | ||||||||
| FaxNumber: | 8187893967 | ||||||||
| Practice Location | |||||||||
| Address1: | 16952 VENTURA BLVD | ||||||||
| Address2: | |||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913164197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187893964 | ||||||||
| FaxNumber: | 8187893967 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 05/07/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DORAFSHAR | ||||||||
| AuthorizedOfficialFirstName: | MOHAMMAD ALI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONSULTANT | ||||||||
| AuthorizedOfficialTelephone: | 8189990099 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.