Provider Demographics
NPI:1730546581
Name:TAHVILDARIAN, MITRA (PHD, AGNP, CFMP)
Entity type:Individual
Prefix:DR
First Name:MITRA
Middle Name:
Last Name:TAHVILDARIAN
Suffix:
Gender:F
Credentials:PHD, AGNP, CFMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15840 VENTURA BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2932
Mailing Address - Country:US
Mailing Address - Phone:818-917-2371
Mailing Address - Fax:
Practice Address - Street 1:15840 VENTURA BLVD
Practice Address - Street 2:301
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2932
Practice Address - Country:US
Practice Address - Phone:818-917-2371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-25
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003672363LG0600X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology