Provider Demographics
NPI:1285737353
Name:A SHAWN VEISEH MD A PROFESSIONAL CORPORATION EXECUTIVE PHYSICAL PROGRA
Entity type:Organization
Organization Name:A SHAWN VEISEH MD A PROFESSIONAL CORPORATION EXECUTIVE PHYSICAL PROGRA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AFSHIN
Authorized Official - Middle Name:SHAWN
Authorized Official - Last Name:VIESEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-208-0708
Mailing Address - Street 1:100 UCLA MEDICAL PLZ
Mailing Address - Street 2:SUITE 720
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-6970
Mailing Address - Country:US
Mailing Address - Phone:310-208-0708
Mailing Address - Fax:310-209-1577
Practice Address - Street 1:100 UCLA MEDICAL PLZ
Practice Address - Street 2:SUITE 720
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-6970
Practice Address - Country:US
Practice Address - Phone:310-208-0708
Practice Address - Fax:310-209-1577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74878261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG74878BMedicare PIN