Provider Demographics
NPI:1699914937
Name:EBRAHIM HAKIMIAN, M.D. INC
Entity type:Organization
Organization Name:EBRAHIM HAKIMIAN, M.D. INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EBRAHIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HAKIMIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-909-9868
Mailing Address - Street 1:14649 VICTORY BLVD
Mailing Address - Street 2:22
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-4101
Mailing Address - Country:US
Mailing Address - Phone:818-909-9868
Mailing Address - Fax:818-909-9871
Practice Address - Street 1:14649 VICTORY BLVD
Practice Address - Street 2:22
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411-4101
Practice Address - Country:US
Practice Address - Phone:818-909-9868
Practice Address - Fax:818-909-9871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-10
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48918208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABL178OtherMEDICARE PROVIDER NUMBER
CA00A489180Medicaid