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General NPI Number Information
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NPI Number | 1346302114
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Entity Type | Organization
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Legal Business Name | ELITE ONCOLOGY MEDICAL GROUP
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Dates
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Enumeration Date | 12/15/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 12099 W WASHINGTON BLVD STE 304
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City | LOS ANGELES
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State | CA
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Zip | 90066-2621
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Country | US
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Telephone | 310-398-0013
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Fax | 310-398-4470
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Provider Business Mailing Address
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Address Line | 12405 VENICE BLVD # 2
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City | LOS ANGELES
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State | CA
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Zip | 90066-3803
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Country | US
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Telephone | 310-397-8654
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Fax | 310-398-4470
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Authorized Official
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Title or Position | DIRECTOR OF MEDICAL ONCOLOGY
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Name | DR. NAZAR AL-BUSSAM
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Credential | M.D.
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Telephone | 310-397-8654
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A026479
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License Number State | CA
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