Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | A97912 | CA |
Y | 207QA0505X | Family Doctor - Adult Medicine | A97912 | CA |
NPI | 1336271055 |
---|---|
Provider Name | Syrus Feridouni |
First Address | Glendale, CA 91205-4433 |
Second Address | Glendale, CA 91205-4433 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/03/2007 |
Last Update Date | 11/07/2007 |