Healthcare Provider Details

I. General information

NPI: 1043545957
Provider Name (Legal Business Name): ALEX A. KHADAVI MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2009
Last Update Date: 10/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16260 VENTURA BLVD SUITE 140
ENCINO CA
91436-5103
US

IV. Provider business mailing address

8539 W SUNSET BLVD SUITE 4 BOX 132
WEST HOLLYWOOD CA
90069-2334
US

V. Phone/Fax

Practice location:
  • Phone: 818-528-2500
  • Fax: 818-528-2505
Mailing address:
  • Phone: 661-974-7954
  • Fax: 661-974-8365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: CATHIE L BYERS
Title or Position: MEDICAL BILLING MANAGER
Credential:
Phone: 661-974-7954