Provider Demographics
NPI:1861717704
Name:GHOMRI, YASHAR M
Entity type:Individual
Prefix:
First Name:YASHAR
Middle Name:M
Last Name:GHOMRI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 E BROADWAY STE 301
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1380
Mailing Address - Country:US
Mailing Address - Phone:310-971-4757
Mailing Address - Fax:855-795-4464
Practice Address - Street 1:1100 E BROADWAY STE 301
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1380
Practice Address - Country:US
Practice Address - Phone:310-971-4757
Practice Address - Fax:855-795-4464
Is Sole Proprietor?:No
Enumeration Date:2010-04-04
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11892207R00000X, 208M00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB209036Medicare PIN