Provider Demographics
NPI:1215295662
Name:POURSHALIMI, DANIEL MAYER (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:MAYER
Last Name:POURSHALIMI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1950 SAWTELLE BLVD STE 130
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-7072
Practice Address - Country:US
Practice Address - Phone:310-996-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA307532207R00000X
NY298144207R00000X, 208M00000X
CAA128413207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA128413OtherSTATE LICENSE
LA2459350Medicaid
CAFP5550404OtherDEA LICENSE