Healthcare Provider Details

I. General information

NPI: 1720110349
Provider Name (Legal Business Name): JAMSHID MADDAHI, MD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 09/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11859 WILSHIRE BLVD STE 110
LOS ANGELES CA
90025-6600
US

IV. Provider business mailing address

100 UCLA MEDICAL PLZ # 410
LOS ANGELES CA
90095-7064
US

V. Phone/Fax

Practice location:
  • Phone: 310-824-4991
  • Fax: 310-824-7082
Mailing address:
  • Phone: 310-824-4991
  • Fax: 310-824-7082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA031808
License Number StateCA

VIII. Authorized Official

Name: MRS. ANGELA MADDAHI
Title or Position: OFFICE MANAGER
Credential:
Phone: 310-824-4991