Healthcare Provider Details

I. General information

NPI: 1235269473
Provider Name (Legal Business Name): DERMATOLOGY & LASER MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 12/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16260 VENTURA BLVD SUITE 140
ENCINO CA
91436-2203
US

IV. Provider business mailing address

PO BOX 261430
ENCINO CA
91426-1430
US

V. Phone/Fax

Practice location:
  • Phone: 818-528-2500
  • Fax: 818-528-2505
Mailing address:
  • Phone: 818-528-2500
  • Fax: 818-528-2505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA71517
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA71517
License Number StateCA

VIII. Authorized Official

Name: DR. ALEX A KHADAVI
Title or Position: OWNER
Credential: M.D.
Phone: 818-528-2500