Provider Demographics
NPI:1215457015
Name:AZIMI, EHSAN (MD)
Entity type:Individual
Prefix:DR
First Name:EHSAN
Middle Name:
Last Name:AZIMI
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 1:713 N DOUGLAS ST
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-2830
Mailing Address - Country:US
Mailing Address - Phone:310-906-2788
Mailing Address - Fax:310-906-2786
Practice Address - Street 1:713 N DOUGLAS ST
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-2830
Practice Address - Country:US
Practice Address - Phone:310-906-2788
Practice Address - Fax:310-906-2786
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-22
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA172626207N00000X
MA272099207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine