Healthcare Provider Details

I. General information

NPI: 1174693352
Provider Name (Legal Business Name): NOUJAN ADL-TABATABAI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 05/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 N HOLLYWOOD WAY SUITE 204
BURBANK CA
91505-1055
US

IV. Provider business mailing address

PO BOX 4565
ONTARIO CA
91761-0819
US

V. Phone/Fax

Practice location:
  • Phone: 818-557-0135
  • Fax:
Mailing address:
  • Phone: 323-440-0998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number232492
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA101867
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: