Provider Demographics
NPI:1699940494
Name:DANESHVAR, SAMUEL A (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:A
Last Name:DANESHVAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:6333 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 410
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5702
Mailing Address - Country:US
Mailing Address - Phone:310-339-7937
Mailing Address - Fax:323-655-1991
Practice Address - Street 1:2020 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2023
Practice Address - Country:US
Practice Address - Phone:310-595-5216
Practice Address - Fax:310-582-6222
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA98722207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1699940494Medicaid
CA1699940494OtherCCS PANELED PROVIDER
CA1699940494Medicaid