Healthcare Provider Details

I. General information

NPI: 1598462749
Provider Name (Legal Business Name): WEST LA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2023
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17609 VENTURA BLVD STE LL08
ENCINO CA
91316-5135
US

IV. Provider business mailing address

17609 VENTURA BLVD STE LL08
ENCINO CA
91316-5135
US

V. Phone/Fax

Practice location:
  • Phone: 818-774-2755
  • Fax:
Mailing address:
  • Phone: 818-774-2755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HOOMAN SHABATIAN
Title or Position: DIRECTOR
Credential: MD
Phone: 818-774-2755