Basic Information
| Provider Information | |||||||||
| NPI: | 1669831459 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INSTITUTE OF DIAGNOSITC MEDICINE & RESEARCH INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 833 S LOS ROBLES AVE | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911063716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105925067 | ||||||||
| FaxNumber: | 7149969267 | ||||||||
| Practice Location | |||||||||
| Address1: | 833 S LOS ROBLES AVE | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911063716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105925067 | ||||||||
| FaxNumber: | 7149969267 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2016 | ||||||||
| LastUpdateDate: | 02/22/2016 | ||||||||
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| AuthorizedOfficialLastName: | POURMAND | ||||||||
| AuthorizedOfficialFirstName: | KHASHAYAR | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3105925067 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZE0600X | N | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Electroneurodiagnostic | 2084N0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1225092190 | 01 | CA | INDIV NPI | OTHER |