Healthcare Provider Details

I. General information

NPI: 1417050782
Provider Name (Legal Business Name): LADDARAN MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 09/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 BEVERLY BLVD STE 117
LOS ANGELES CA
90057
US

IV. Provider business mailing address

2105 BEVERLY BLVD STE 117
LOS ANGELES CA
90057
US

V. Phone/Fax

Practice location:
  • Phone: 213-413-8742
  • Fax: 213-413-6482
Mailing address:
  • Phone: 213-413-8742
  • Fax: 213-413-6482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA365070
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA365910
License Number StateCA

VIII. Authorized Official

Name: ANITA CHUA LADDARAN
Title or Position: PRESIDENT
Credential:
Phone: 213-413-8742