Healthcare Provider Details

I. General information

NPI: 1962498410
Provider Name (Legal Business Name): RAED BARGOUT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 04/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N VERMONT AVE 401
LOS ANGELES CA
90027-6005
US

IV. Provider business mailing address

1300 N VERMONT AVE 401
LOS ANGELES CA
90027-6005
US

V. Phone/Fax

Practice location:
  • Phone: 323-664-6535
  • Fax:
Mailing address:
  • Phone: 323-664-6535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberC53521
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: