Healthcare Provider Details

I. General information

NPI: 1811144561
Provider Name (Legal Business Name): NEIL S. GHODADRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2008
Last Update Date: 04/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 S SPALDING DR SUITE 401
BEVERLY HILLS CA
90212-1800
US

IV. Provider business mailing address

10780 SANTA MONICA BLVD SUITE 210
LOS ANGELES CA
90025-4749
US

V. Phone/Fax

Practice location:
  • Phone: 310-860-3048
  • Fax: 310-550-7680
Mailing address:
  • Phone: 310-453-5404
  • Fax: 310-453-2535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number125-050000
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA116163
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: