Healthcare Provider Details

I. General information

NPI: 1962680348
Provider Name (Legal Business Name): EDGAR MEHDIKHANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2008
Last Update Date: 08/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 W EULALIA ST SUITE 114
GLENDALE CA
91204-2849
US

IV. Provider business mailing address

222 W EULALIA ST SUITE 114
GLENDALE CA
91204-2849
US

V. Phone/Fax

Practice location:
  • Phone: 818-242-8916
  • Fax: 818-241-7708
Mailing address:
  • Phone: 818-242-8916
  • Fax: 818-241-7708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberA96024
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: