Provider Demographics
NPI:1164950689
Name:AMIDI, OMID (MD)
Entity type:Individual
Prefix:
First Name:OMID
Middle Name:
Last Name:AMIDI
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 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-301-8707
Mailing Address - Fax:
Practice Address - Street 1:2625 W ALAMEDA AVE STE 102
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4815
Practice Address - Country:US
Practice Address - Phone:818-843-9032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-29
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA170248207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty