Healthcare Provider Details

I. General information

NPI: 1629459896
Provider Name (Legal Business Name): ALITIA KANDASAMY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2015
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 BEVERLY BLVD STE 4221
WEST HOLLYWOOD CA
90048-1804
US

IV. Provider business mailing address

4140 W 190TH ST
TORRANCE CA
90504-5513
US

V. Phone/Fax

Practice location:
  • Phone: 310-423-4667
  • Fax:
Mailing address:
  • Phone:
  • Fax: 323-361-8052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA162869
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: