Healthcare Provider Details

I. General information

NPI: 1639400260
Provider Name (Legal Business Name): ASSUTA FAMILY MEDICAL GROUP A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2010
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12922 VICTORY BLVD
NORTH HOLLYWOOD CA
91606-2924
US

IV. Provider business mailing address

12922 VICTORY BLVD
NORTH HOLLYWOOD CA
91606-2924
US

V. Phone/Fax

Practice location:
  • Phone: 818-760-2800
  • Fax: 818-760-7343
Mailing address:
  • Phone: 818-760-2800
  • Fax: 818-760-7343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA82603
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA33650
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberA60294
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberA60294
License Number StateCA

VIII. Authorized Official

Name: NATARAJ CHANDRASEKHAR
Title or Position: MANAGER
Credential:
Phone: 818-760-2800