Healthcare Provider Details

I. General information

NPI: 1467475442
Provider Name (Legal Business Name): WALEED QAISI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2428 SANTA MONICA BLVD
SANTA MONICA CA
90404-2045
US

IV. Provider business mailing address

2701 NW VAUGHN ST STE 425
PORTLAND OR
97210-5311
US

V. Phone/Fax

Practice location:
  • Phone: 310-315-1000
  • Fax:
Mailing address:
  • Phone: 503-227-2400
  • Fax: 503-227-0218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberC168272
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD23292
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: