Provider Demographics
NPI:1174715965
Name:BROUKHIM, SEPEHR (DO)
Entity type:Individual
Prefix:
First Name:SEPEHR
Middle Name:
Last Name:BROUKHIM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15233 VENTURA BLVD
Mailing Address - Street 2:STE 1108
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403
Mailing Address - Country:US
Mailing Address - Phone:818-590-2646
Mailing Address - Fax:
Practice Address - Street 1:15233 VENTURA BLVD
Practice Address - Street 2:STE 1108
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403
Practice Address - Country:US
Practice Address - Phone:818-590-2646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-15
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A93072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020A93070Medicaid
CACA376ZMedicare PIN