Provider Demographics
NPI:1427118355
Name:DARDASHTI, BEHROUZ ELIA (MD)
Entity type:Individual
Prefix:
First Name:BEHROUZ
Middle Name:ELIA
Last Name:DARDASHTI
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 1:5363 BALBOA BLVD
Mailing Address - Street 2:#546
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316
Mailing Address - Country:US
Mailing Address - Phone:818-995-6003
Mailing Address - Fax:818-995-3862
Practice Address - Street 1:5363 BALBOA BLVD
Practice Address - Street 2:#546
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316
Practice Address - Country:US
Practice Address - Phone:818-995-6003
Practice Address - Fax:818-995-3862
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38320207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A38370Medicaid
A38320AMedicare ID - Type Unspecified
CA00A38370Medicaid