Healthcare Provider Details

I. General information

NPI: 1316185788
Provider Name (Legal Business Name): WESTERN PODMED CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2009
Last Update Date: 01/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S CENTRAL AVE STE 323
GLENDALE CA
91204-2530
US

IV. Provider business mailing address

1500 S CENTRAL AVE STE 323
GLENDALE CA
91204-2530
US

V. Phone/Fax

Practice location:
  • Phone: 818-243-0400
  • Fax: 818-507-9902
Mailing address:
  • Phone: 818-243-0400
  • Fax: 818-507-9902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE4513
License Number StateCA

VIII. Authorized Official

Name: MARTIN MORADIAN
Title or Position: PRESIDENT
Credential: DPM
Phone: 818-243-0400