Provider Demographics
NPI:1194091496
Name:SASSAN DAVOUDI, MD PC
Entity type:Organization
Organization Name:SASSAN DAVOUDI, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SASSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVOUDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-345-6655
Mailing Address - Street 1:5071 GARDEN GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-4317
Mailing Address - Country:US
Mailing Address - Phone:818-345-6655
Mailing Address - Fax:
Practice Address - Street 1:5071 GARDEN GROVE AVE
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-4317
Practice Address - Country:US
Practice Address - Phone:818-345-6655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI46702Medicare UPIN