Healthcare Provider Details

I. General information

NPI: 1801167044
Provider Name (Legal Business Name): GLENDALE DOCTORS MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2012
Last Update Date: 06/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1123 S. CENTRAL AVE
GLENDALE CA
91204-2212
US

IV. Provider business mailing address

1123 S. CENTRAL AVE
GLENDALE CA
91204-2212
US

V. Phone/Fax

Practice location:
  • Phone: 818-242-8805
  • Fax: 818-242-4442
Mailing address:
  • Phone: 818-242-8805
  • Fax: 818-242-4442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number9962
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA32929
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberA41065
License Number StateCA

VIII. Authorized Official

Name: MR. TAHSIN ALI WAHEB
Title or Position: CEO
Credential: MD
Phone: 818-242-8805