Provider Demographics
NPI:1063078764
Name:KIMIABAKHSH, BRYAN DANIEL (MD, MS)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:DANIEL
Last Name:KIMIABAKHSH
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 HEMLOCK DRIVE
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11024
Mailing Address - Country:US
Mailing Address - Phone:516-984-9199
Mailing Address - Fax:
Practice Address - Street 1:2021 SANTA MONICA BLVD STE 625E
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2169
Practice Address - Country:US
Practice Address - Phone:310-829-8948
Practice Address - Fax:424-212-5937
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA196784207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program