Basic Information
| Provider Information | |||||||||
| NPI: | 1518983063 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANOONI | ||||||||
| FirstName: | MARJAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5767 W CENTURY BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900455631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103018774 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 335 N LA BREA AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900362517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236343850 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 12/09/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/09/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0000X | A82603 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | Adolescent Medicine | 207Q00000X | A82603 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1518983063 | 01 | CA | A82603 | OTHER | A82603 | 01 | CA | STATE LICENSE | OTHER | 1518983063 | 05 | CA | MEDICAID |