Healthcare Provider Details

I. General information

NPI: 1013979822
Provider Name (Legal Business Name): DR. ALI REZA SADRIEH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 10/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12265 VENTURA BLVD SUITE 107
STUDIO CITY CA
91604-2528
US

IV. Provider business mailing address

PO BOX 1360
STUDIO CITY CA
91614-0360
US

V. Phone/Fax

Practice location:
  • Phone: 310-691-5411
  • Fax: 310-388-1658
Mailing address:
  • Phone: 310-691-5411
  • Fax: 310-388-1658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE4318
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: