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General NPI Number Information
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NPI Number | 1326299496
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Entity Type | Organization
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Legal Business Name | DERMATOLOGY & LASER MEDICAL CTR INC
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Dates
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Enumeration Date | 10/07/2008
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Last Update Date | 07/18/2011
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Provider Practice Location Address
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Address Line | 16260 VENTURA BLVD SUITE 140
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City | ENCINO
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State | CA
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Zip | 91436-2203
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Country | US
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Telephone | 818-528-2500
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Fax | 818-528-2505
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Provider Business Mailing Address
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Address Line | PO BOX 261430
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City | ENCINO
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State | CA
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Zip | 91426-1430
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Country | US
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Telephone | 661-575-0003
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Fax | 661-575-0006
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Authorized Official
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Title or Position | OWNER
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Name | DR. ALEX A KHADAVI
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Credential | M.D.
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Telephone | 818-528-2500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number | A71517
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 207ND0900X
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Taxonomy Name | Dermatopathology Physician
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License Number | A71517
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 207NS0135X
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Taxonomy Name | Procedural Dermatology Physician
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License Number | A71517
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License Number State | CA
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