Healthcare Provider Details

I. General information

NPI: 1518596584
Provider Name (Legal Business Name): ALI ALJIDUI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 N PROSPECT AVE STE 103
REDONDO BEACH CA
90277-3037
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-937-8555
  • Fax:
Mailing address:
  • Phone: 310-301-8707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA182075
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA182075
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: