Provider Demographics
NPI:1174615629
Name:GHADIMI, KAMRAN (MD)
Entity type:Individual
Prefix:
First Name:KAMRAN
Middle Name:
Last Name:GHADIMI
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 1:1412 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3507
Mailing Address - Country:US
Mailing Address - Phone:310-548-5481
Mailing Address - Fax:310-548-5000
Practice Address - Street 1:1412 W 7TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3507
Practice Address - Country:US
Practice Address - Phone:310-548-5481
Practice Address - Fax:310-548-5000
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50028207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A500280Medicaid
CAA50028BMedicare ID - Type Unspecified
CAF20697Medicare UPIN