Healthcare Provider Details

I. General information

NPI: 1942414024
Provider Name (Legal Business Name): KATRIN LALEZARZADEH D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 12/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16550 VENTURA BLVD SUITE 414
ENCINO CA
91436-2004
US

IV. Provider business mailing address

16550 VENTURA BLVD SUITE 414
ENCINO CA
91436-2004
US

V. Phone/Fax

Practice location:
  • Phone: 818-783-3110
  • Fax: 818-783-3115
Mailing address:
  • Phone: 818-783-3110
  • Fax: 818-783-3115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20A10295
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080H0002X
TaxonomyPediatric Hospice and Palliative Medicine Physician
License Number2418181
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: