Healthcare Provider Details

I. General information

NPI: 1942607932
Provider Name (Legal Business Name): MONZER KADDOUR MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2014
Last Update Date: 05/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19528 VENTURA BLVD 468
TARZANA CA
91356-2917
US

IV. Provider business mailing address

19528 VENTURA BLVD 468
TARZANA CA
91356-2917
US

V. Phone/Fax

Practice location:
  • Phone: 661-287-3162
  • Fax: 661-287-3951
Mailing address:
  • Phone: 661-287-3162
  • Fax: 661-287-3951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC53238
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberC53238
License Number StateCA

VIII. Authorized Official

Name: MONZER KADDOUR
Title or Position: CEO
Credential: MD
Phone: 312-451-4308